Differential Diagnosis of Psychotic Symptoms: Medical “Mimics”
Oct 01, · Bipolar disorder, current episode manic severe with psychotic features. Billable/Specific Code. F is a billable/specific ICDCM. Nov 06, · Major Depression with Psychotic Features (Psychotic Depression) Medically reviewed by Timothy J. Legg, Ph.D., CRNP Learn about the causes and symptoms of psychotic depression and how the disorder.
Diagnosis Index entries containing back-references to F Toggle navigation. Applicable To Bipolar disorder, current episode manic with mood-congruent psychotic symptoms Bipolar disorder, current episode manic with mood-incongruent psychotic symptoms Bipolar I disorder, current or most recent episode manic with psychotic features. The following code s above F In this context, annotation back-references refer to pscyhotic that contain: Applicable To annotations, or Code Also annotations, or Code First annotations, or Excludes1 annotations, or Excludes2 annotations, or Includes annotations, or Note annotations, or Use Additional annotations.
Mental, Behavioral and Neurodevelopmental disorders Includes disorders of psychological what is meant by sinuous curve. Type 2 Excludes symptoms, bjpolar and abnormal clinical laboratory findings, not elsewhere classified RR Type 1 Excludes bipolar disorder, single manic episode F Type 2 Excludes cyclothymia F Type 2 Excludes schizophrenic reaction in: alcoholism F Type 1 Excludes mood [affective] disorders with psychotic symptoms F Type 2 Excludes paranoid personality disorder F Type 2 Excludes mood [affective] disorders with psychotic symptoms F F31 Bipolar disorder.
Depression with psychosis is more common than you think but treatment is effective. Learn more
Nov 04, · Psychotic depression is taken very seriously by mental health professionals because the individual suffering from it is at an increased risk of self-harm. “The suicide rate in people with psychotic depression, when they are ill and in their acute phase, is much higher than it is with major depression,” says Anthony J. Rothschild, MD, the Irving S. and Betty Brudnick Endowed Chair. Psychotic Depression. People with psychotic depression have the symptoms of major depression along with "psychotic" symptoms, such as: Hallucinations (seeing or hearing things that aren't there. People experiencing an episode with mixed features may feel very sad, empty, or hopeless, while, at the same, time feeling extremely energized. A person may have bipolar disorder even if their symptoms are less extreme. For example, some people with bipolar disorder (Bipolar II) experience hypomania, a less severe form of mania.
The number of medical diseases that can present with psychotic symptoms ie, delusions, hallucinations is legion. A thorough differential diagnosis of possible medical and toxic causes of psychosis is necessary to avoid the mistaken attribution of psychosis to a psychiatric disorder. Crude exogenous organic damage of the most varying kind can produce acute psychotic clinical pictures of a basically uniform kind. In this article, I focus on secondary psychosis due to a medical illness or substances and not on the cognitive disorders of delirium and dementia.
It is important, however, to be aware that both are commonly associated with psychosis. Psychosis is a frequent ancillary symptom of delirium that can overshadow its cardinal cognitive features. It is therefore critical to routinely consider the possibility of a delirium in any patient with psychosis.
Dementias are also frequently accompanied by neuropsychiatric problems, including psychosis. Most patients with Lewy body dementia experience psychosis as well. A primary psychotic disorder, such as schizophrenia, is a diagnosis of exclusion, and all patients with new-onset psychosis need a medical workup that excludes medical-toxic causes of psychosis.
The overall clinical and epidemiological situation is of utmost importance in narrowing the initially rather broad differential diagnosis of psychosis to keep the workup manageable and to determine the degree of urgency. For example, any new-onset psychosis in a hospitalized, elderly patient following hip surgery is most likely a toxic psychosis delirium ; an antisocial patient with polysubstance dependence who presents at the emergency department is likely suffering from a drug-induced psychosis.
Some medical diagnoses are difficult to make. Clinicians might also not recognize a common disease if it presents in an atypical manner eg, HIV infection presenting with psychosis. Table 1 provides examples of diagnostic mistakes. A thorough history and physical examination with emphasis on the neurological and cognitive parts are the cornerstones for the initial approach to psychosis. To detect fluctuations in mental status typical for a toxic psychosis, repeated visits with bedside testing of cognition may be necessary.
The extent of the laboratory workup to complement the history and physical examination is a matter of debate, and there is no agreed-on workup. For example, the rapid plasma reagin RPR is not the most sensitive test for neurosyphilis, and a negative result could be a false negative; if one were to truly want to rule out neurosyphilis, a treponemal-specific test would be needed.
If there is a strong clinical suspicion for a disease, its diagnosis must be actively pursued with repeated tests eg, serial electroencephalograms [EEGs] for epilepsy. Finally, a positive finding on an examination or a positive laboratory test result alone eg, a urine drug test positive for cannabis does not establish causality.
This point is perhaps most relevant with regard to incidental findings on a sensitive neuroimaging modality, such as a brain MRI. One possible medical workup is outlined in Table 2. The suggested laboratory battery is a compromise between broad-based screening eg, erythrocyte sedimentation rate for inflammatory conditions and exclusion of some specific conditions that are treatable if diagnosed eg, HIV infection, syphilis, thyroid disease, vitamin B12 deficiency.
If there is clinical concern for a delirium, EEGs, arterial blood gases, or lumbar punctures become more important. Of note, there is no consensus regarding the need for routine brain imaging in first-episode psychosis. A normal baseline CT or MRI scan, however, is reassuring and can help patients and families accept that medical and neurological causes of illness have been excluded.
The appropriate role of routine genetic screening in patients with psychosis is an area in flux. Currently, only the Clinical Practice Guidelines for the Treatment of Schizophrenia by the Canadian Psychiatric Association recommends testing for a genetic syndrome, the velocardiofacial syndrome, but only if it is clinically suspected.
Endocrine diseases. Endocrine diseases are the prototype for systemic illnesses that affect the brain and lead to a wide variety of neuropsychiatric symptoms. Thyroid disease in the form of hyperthyroidism or hypothyroidism myxedema madness can be associated with psychosis.
Metabolic diseases. Among the metabolic disorders, only acute intermittent porphyria AIP is sufficiently common to be routinely considered in patients with psychosis, particularly if abdominal complaints colicky pain, severe constipation and peripheral motor neuropathy are present. These defects could result in an accumulation of the porphyrin precursors, porphobilinogen PBG and aminolevulinic acid ALA.
The course of AIP is episodic, and patients are well between episodes. Fasting, alcohol, and a host of porphyrogenic medications can trigger episodes. Tay-Sachs disease GM2 gangliosidosis type 1 and Niemann-Pick disease type C are rare storage disorders that have adult-onset variants.
Psychosis is one of the possible symptoms. Systemic lupus erythematosus SLE is a multisystem autoimmune disease for which 2 CNS symptoms, psychosis and seizures, have long been recognized as diagnostic criteria by the American College of Rheumatology. Moreover, psychosis correlated with markers of SLE disease activity.
Other autoimmune disorders to be considered include Hashimoto encephalopathy and paraneoplastic syndromes.
Hashimoto encephalopathy is associated with autoimmune thyroiditis and recurrent episodes of psychosis. Although PLE is most commonly associated with small-cell lung cancer, many other tumors have been implicated.
A young woman who presents with psychosis that progresses to seizures, autonomic instability, and unresponsiveness should have a workup for ovarian tumors because she might have encephalitis associated with N -methyl d-aspartate NMDA receptor antibodies. Immigrant populations or travelers can present with diseases associated with psychosis that would be considered uncommon in the United States eg, cerebral malaria, toxoplasmosis, neurocysticercosis, sleeping sickness.
HIV infection and neurosyphilis are treatable diseases that affect the brain. They can present with psychosis and should specifically be considered in all patients with psychosis. In contrast to neurosyphilis, the link between chronic psychosis and another spirochetal disease, neuroborreliosis, is controversial, although it has been linked to acute psychosis in a case report.
Narcolepsy is characterized by the tetrad of excessive daytime sleepiness, cataplexy, sleep paralysis, and hypnagogic hallucinations ie, vivid auditory or visual illusions that occur when falling asleep.
In some patients, prominent psychosis-like experiences occur throughout the day and overshadow other symptoms of narcolepsy that can lead to a mistaken diagnosis of schizophrenia. Human leukocyte antigen testing and cerebrospinal fluid levels of hypocretin-1 can further assist in making the correct diagnosis. The link between seizures, particularly temporal lobe epilepsy, and psychosis is well established. Ictal psychosis can occur in complex partial or absence status epilepticus.
Postictal psychosis emerges close to the seizure and can last several days or weeks, rarely morphing into a chronic psychosis. Confusion, episodic violence, and catatonia are clinical symptoms that should raise suspicion for seizures.
If a seizure or epilepsy is suspected, the diagnosis needs to be pursued appropriately. A normal, routine interictal EEG is insufficient to exclude epilepsy. Serial EEGs and optimal lead placement improve the chances of making a diagnosis of epilepsy. A high index of suspicion based on history abrupt onset and cessation of bizarre motor automatisms and vocalizations but little if any postictal confusion combined with EEG monitoring and alternative electrode placement eg, pharyngeal leads can succeed in making this diagnosis.
Space-occupying lesions. Primary or secondary brain tumors can cause psychosis as their first manifestation and should be considered in elderly patients, particularly if there is a persistent headache or other neurological signs, including seizures.
Temporal lobe location is thought to increase the likelihood of psychosis, although it must be stressed that no lesion location in the brain reliably produces psychosis. Causal attribution of psychosis to incidental neuroimaging findings eg, cysts or vascular malformations in the temporal lobes is therefore often unclear.
Conditions that increase intracranial pressure, such as normal pressure hydrocephalus, have been associated with psychosis as well. Rarely, psychosis can be the presenting symptom of a stroke. The sudden onset of complex visual hallucinations should lead to consideration of 2 lesion-related conditions: peduncular hallucinosis caused by focal midbrain peduncular lesions and the Charles Bonnet syndrome following occipital infarction. Head injury. A history of head injury is a risk factor for the development of a chronic psychotic syndrome that can be clinically indistinguishable from schizophrenia.
Head injury—related psychosis is typically a mostly paranoid-hallucinatory syndrome that develops insidiously several years after injury. The severity of head injury as judged by the duration of loss of consciousness and a family history of psychosis are 2 variables associated with the emergence of psychosis following head injury. Demyelinating diseases. Diseases that disrupt the integrity of white matter tracts in the brain can lead to psychosis, likely to be caused by the functional disconnectivity of critical brain regions.
Multiple sclerosis, the most common demyelinating disease, is associated with psychosis more often than can be expected by chance, although the rate of psychosis is low.
ALD is an X-linked disorder in which very-long-chain fatty acids accumulate because of defective peroxisomal oxidation. While inherited leukodystrophies are typically diagnosed in childhood because of their aggressive clinical course with systemic and neurological symptoms, adult-onset cases can present with a predominantly psychiatric picture. The diagnosis of a demyelinating disorder is suggested by abnormal findings on MRI scans.
Clinical red flags for inherited leukodystrophies include progressive cognitive decline, other neurological findings eg, seizures or a neuropathy , or other systemic findings eg, adrenal insufficiency in patients with ALD. Basal ganglia disorders. Rare, inherited basal ganglia disorders associated with psychosis include Wilson disease, Huntington disease, and Fahr disease. Since early diagnosis and treatment can prevent irreversible end-organ damage, screening with hour urinary copper and serum ceruloplasmin levels should be considered in psychotic patients, particularly if patients show evidence of liver abnormalities.
Kayser-Fleischer rings of the cornea as detected by slitlamp examination are not always present in neuropsychiatric Wilson disease.
The diagnosis of Huntington disease, an autosomal dominant disorder, is usually not difficult because most patients will have a family history. Psychosis can precede the motor symptoms of Huntington disease and delay its recognition. Fahr disease is characterized by bilateral basal ganglia calcifications and neuropsychiatric symptoms, including psychosis.
Hallucinations, particularly visual hallucinations, are a common problem associated with Parkinson disease. Nutritional deficiencies. Vitamin B12 deficiency is easily correctable and should be specifically excluded in all patients. Psychosis from vitamin B12 deficiency can predate anemia and the typical spinal symptoms.
Many toxins, drugs, and medications can cause psychosis without a delirium, although the line between secondary psychosis caused by a substance and toxic psychosis can be difficult to draw. In addition, establishing a causal link between substances and psychosis is not always possible, and in many circumstances of illicit drug use in particular, the exact relationship between psychotic symptoms and the ingested drug requires long-term follow-up.
In cases of cannabis use and a psychotic illness, an interaction between drug use and genetic predisposition to schizophrenia is likely. Inquiring about all drugs and medications taken eg, over-the-counter, bought over the Internet, prescribed, nonprescribed, illicit and an exposure history occupation and hobbies such as gardening can provide clues that guide further investigation.
An herbal preparation associated with psychosis is the now-banned ephedra that patients might take for weight loss. While uncommon and most importantly idiosyncratic as opposed to dose-related , psychosis is a possible complication of recreational anabolic steroid use.
The detection of environmental toxin poisoning requires a high index of suspicion. Toxins to consider include carbon monoxide; organophosphates; and heavy metals, particularly arsenic, manganese, mercury, and thallium.
In many clinical settings, alcohol, sedative-hypnotics, and illicit drugs will be common causes of psychosis. Alcohol and sedative-hypnotics can lead to psychosis during intoxication rare , during withdrawal, or during a delirium tremens.