PREVENTIVE PSYCHIATRY ?
C. Norman Shealy, M.D., Ph.D.
Dr. Gary Kohls has given me permission to share with you any of his superb newsletters. I have long enjoyed his commentaries and from time to time you will have an opportunity to read those I consider too important to miss!? If you want to hear more from Gary, there is a link at the end.
Preventive Psychiatry E-Newsletter # 355
?Organic (Neurological/Non-psychological) Causes of “Mental Illnesses”
(that should never be treated with long-term psychiatric drugs!)
Remember:1) Psychosis is not the same as schizophrenia!; 2) If you do not look for organic causes you will not find them; and 3)? be suspicious of “medical clearances”
1. Symptoms that suggest organic disease include:
1. A patient with no previous psychiatric history
2. Hallucinations that are visual, vivid in color, or that change rapidly; Olfactory (smell) hallucinations
3. Illusions: misinterpretations of stimuli
4. Recent weight changes; chronic or acute malnutrition; sleep deprivation
5. Ingestion of toxic substances as food; other poisoning by toxic ingestion, inhalation or injection (including vaccinations)
6. Significant psychological trauma, especially chronic and severe
7. Head injury (traumatic brain injury = TBI)
2. Medical emergencies that can present as psychiatric illness:
Syndromes related to chronic alcohol usage or withdrawal, including Delerium Tremens and other forms of alcoholic encephalopathy; hypoxia? (low blood oxygen); meningitis/encephalitis; subarachnoid hemorrhage; adverse drug effects; cardio-pulmonary diseases.
Psychosis vs. Delirium
Psychosis refers to an impairment in reality testing because of hallucinations, delusions or grossly
disorganized thinking. Psychosis can be caused by organic diseases where the cause is knowable or by a variety of mental illnesses ranging from a brief reactive psychosis to schizophrenia.
Delirium refers to an acute organic brain syndrome causing a global cognitive impairment, with
disorientation, memory impairment, and disturbances of consciousness. Illnesses causing deliriums are often life threatening, and a delirium should be considered to be a medical emergency.
Symptoms of delirium include:
1. Disorientation or memory impairment
2. Fluctuating or impaired level of consciousness, decreased awareness of environment
3. Labile affect
4. Impaired judgment or impaired insight
5. Abnormal autonomic signs (changes in blood pressure, pulse, temperature, abnormal sweating,
Medical Illnesses that can Present as Psychoses
1. Progressive neurological diseases Multiple sclerosis, Huntington's chorea and Alzheimer's disease can present as dementia
2. Central nervous system infections
Encephalitis, Meningitis, HIV
3. Space occupying lesions within the skull
Brain tumors, hemorrhage, abscesses
4. Metabolic disorders
a. Accumulation of toxins from severe liver or kidney disease
b. Disturbances in electrolytes
c. Acute intermittent porphyria
d. Wilson's disease: abnormality of copper metabolism that causes damage to brain and liver.
e. Systemic lupus erythematosis (and other autoimmune diseases)
5. Endocrine disorders
Hypothyroidism, Cushing's syndrome and Hypoglycemia, either from insulin secreting tumor or administration of insulin
6. Deficiency states/Malnutrition
a. Thiamine deficiency: Wernicke-Korsakoff amnestic syndrome
b. Pellegra (nicotinic acid deficiency) and other B complex deficiencies, esp. vitamin B6
c. Zinc deficiency
7. Temporal lobe epilepsy (or partial complex seizure disorder) or seizures caused by withdrawal from anti-epileptic drugs, tranquilizers or “mood stabilizers”
a. Legal prescription drugs: psychostimulants such as, Ritalin, Effexor, Wellbutrin, Adderall, Strattera, and other amphetamines; SSRIs, antipsychotics, tranquilizers, L-DOPA
b. Illicit drugs: cocaine, crack, methamphetamine, Ecstasy, Dexedrine, LSD, hallucinogens
Anxiety/Nervousness/Mania (So-Called Bipolar “Disorder”)
1. Psychological manifestations: Inner feelings of terror, tension, apprehension and dread,
derealization, depersonalizations, fear of impending insanity
2. Intellectual disturbances: Decreased concentration, disorganized thinking, loss of IQ
3. Somatic manifestations: Autonomic or visceral symptoms, including palpitations, chest pain, tachycardia, fatigue, weakness, perspiration, flushing, numbness, tingling of extremities, vertigo, shortness of breath, headache, blurred vision, tinnitus, diarrhea, tremor, fainting
Medical Illnesses that can Present with Anxiety/Nervousness/Mania
Strongly suspect medical causes for anxiety in patients who suddenly develop nervousness which disrupts their normal activity
1. A multitude of organic brain syndromes, including these neurological illnesses (representing 25% of medical causes of anxiety syndromes)
a. Cerebral vascular insufficiency/transient ischemic attacks (TIAs).
b. Anxiety states and personality changes following traumatic brain injuries (TBI)
c. Infections of the central nervous system
d. Degenerative disorders
e. Toxic Disorders
f Lead Intoxication
g Mercury intoxication: from contaminated fish, dental fillings, vaccinations
h Manganese intoxication: from industrial exposure
i Organophosphate insecticides (similar to nerve gas): from chemical or insecticide exposure
j. Partial complex seizures
2. Endocrine disorders (25% of medical causes of anxiety symptoms)
a. Hyperthyroidism (increased thyroid hormone).
b. Adrenal hyperfunction or Cushing's syndrome.
c. Hypoglycemia (decreased blood glucose).
d. Hypoparathyroidism (decreased parathyroid hormone).
e. Menopausal and premenstrual syndromes.
3. Cardiopulmonary disorders: Often presents with shortness of breath, rapid breathing, complaints of chest pain, chest pain.
b. Pulmonary embolus
c. Arrhythmias (irregularities of heart beat)
d. Chronic obstructive pulmonary disease (COPD)
e. Mitral valve prolapse (generally harmless)
4. Pheochromocytoma (epinephrine secreting tumors)
?Medications as a Cause of Anxiety/Nervousness
1. Non-psychotropic drugs
a. Sympathomimetics (often found in non-prescription cold and allergy medications): epinephrine, norephinephrine, isoproteronol, levodopa, dopamine hydrochloride, dobutamine, terbutaline sulfate, ephedrine, pseudo-ephedrine
b. Xanthene derivatives (asthma medications, coffee, colas, over-the-counter pain remedies):
aminophylline, theophylline, caffeine
c. Anti-inflammatory agents: indomethacin
d. Thyroid preparations
e. Insulin (via hypoglycemic reaction)
g. Others: nicotine, caffeine, monosodium glutamate (MSG)
h. Withdrawal from caffeine and/or nicotine
2. Psychotropic drugs
a. Antidepressants; SSRIs, tricyclics, Ritalin and other psychostimulant drugs (for treatment of “ADHD”)
b. Tranquilizing drugs: antipsychotics (akathisia may present as anxiety); “mood-stabilizers”
c. Anticholinergic medications; sedating antihistamines (found in over-the-counter sleep
preparations); antiparkinsonian agents.
3. Licit and illicit drugs can cause anxiety and severe insomnia while taking them or while withdrawing from them
a. Caffeine-intoxication or withdrawal
b. Nicotine intoxication or withdrawal
c. Alcohol intoxication or withdrawal
d. Stimulants-cocaine, amphetamines, etc
Many varieties of expression: “Major” depression: (deep and/or long-lasting depression (either single episode or recurrent); “Dysthymia” (mild and/or brief episodes of depression).; adjustment reaction with depressed mood; and bereavement
Medical Illnesses that can Present as Depression/Sadness
1. Depressive syndromes caused by viral illnesses: influenza, infectious mononucleosis, viral hepatitis, viral pneumonia, and viral encephalitis
2. Cancer of all types
3. Cardiopulmonary disease, especially with hypoxia
4. Sleep apnea: should be suspected in a patient with sleep disturbance and daytime somnolence
5. Endocrine Diseases
b. Hyperthyroidism or thyrotoxicosis
c. Adrenal hypofunction (Addison's Disease) or hyperfunction (Cushing's Disease)
e. Post-partum status, post menopausal, and premenstrual syndromes
6. Collagen-Vascular Diseases
This is a strange set of different diseases where the person essentially becomes allergic to parts of
their own body. It can affect all parts of the body Systemic lupus erythematosus (SLE) is most often seen in women 13-40 years old. Scleroderma;? Dermatomyositis
7. Central Nervous System Diseases
a. Multiple Sclerosis
b. Brain tumors, hemorrhages and other intracranial masses.
c. Complex partial seizures
d. Strokes, especially affecting left side of brain (right side of body)
Many Rx Drugs, even Antidepressants, can Cause Depression/Sadness
In one study of family practice patients, 43% of patients diagnosed as depressed were taking medications that can cause depression!
1. All antihypertensive medications can cause depression!
2. Digitalis as well as many other cardiac drugs
3. All anti-acidity drugs
4. NSAIDs (non-steroidal anti-inflammatory drugs)
5. Antidepressants and antipsychotic medications: can cause permanent Parkinsonian dyskinesia or akinesia (inhibition of spontaneity) that can both feel and look like true depression
6. All anxiolytics/tranquilizers, “mood stabilizers” and sedative hypnotics can cause depression
7. Steroids (prednisone and cortisone)
9. Interferon (for treatment of hepatitis C infections)
Remember: Withdrawal from legal and illicit drugs, whether abused, over-used, abruptly discontinued, slowly tapered or not, commonly causes potentially serious syndromes that are NOT mental illnesses, including anxiety/nervousness, depression, suicidality, aggression, akathisia, insomnia, irrational thinking, fatigue and tiredness. ALL drugs of abuse can actually cause depression.
Bipolar Disorder is very commonly simply agitation, anxiety, insomnia an/or hyperstimulation caused by agitation-inducing SSRI antidepressants that are prescribed for a pre-existing “unipolar depression”. Thus the so-called bipolar disorder that has “emerged” is actually a misnomer and should instead be called unipolar sadness with drug-induced mania rather than Bipolar Disorder of unknown cause!