Table Of ContentNeuropsychiatric 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
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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
