Multiple Sclerosis
Multiple sclerosis (MS) is another autoimmune disorder that has a higher prevalence in young women. The disease is characterized by central nervous system involvement that occurs over a period of months to years, with symptoms corresponding to different anatomic locations. Though the classic presenting symptom of MS is optic neuritis, neuropsychiatric syndromes are a common co-occurrence and can be the initial presenting symptom. The most commonly associated psychiatric complaints are anxiety, depression, and bipolar disorder, though case reports of SLE have described acute psychosis, psychotic depression, and adult-onset tic disorder.20
Trauma
Subarachnoid Hemorrhage
Long-term psychiatric sequelae from subarachnoid hemorrhage, either traumatic or aneurysmal, manifest most commonly as personality changes, intellectual impairment, depression, and anxiety. This condition is also known to cause a host of more bizarre psychiatric presentations, such as new-onset kleptomania, akinetic mutism, confabulatory amnesia, acute psychosis, and Capgras syndrome (the delusion that familiar individuals have been replaced by imposters). These symptoms can occur at initial presentation, and may show variable improvement with shunt surgery.21
Subdural Hematoma
Acute or chronic subdural hematoma can result from major head trauma, or even quite minor head trauma in an elderly or coagulopathic patient. Some common psychiatric manifestations of subdural hematoma include cognitive impairment, withdrawn behavior, blunted affect otherwise mimicking schizophrenic psychosis, and catatonia. The EP should consider early imaging studies in patients with new-onset psychotic symptoms—especially when they are refractory to typical antipsychotics.22
Central Nervous Symptom Diseases
Huntington Disease
Huntington disease (HD) is an autosomal dominant inherited, progressive neurodegenerative disorder characterized by mental decline, mood disorder, and muscle coordination problems that eventually become the classic involuntary writhing termed chorea. Due to its progressive nature, precise onset of the disease is difficult to describe; however, HD can manifest initially as schizophrenia-like psychotic episodes with only minimal apparent motor difficulty. Family history, including movement disorders and suicide, is important to obtain when available.23
Parkinson Disease
A progressive and disabling neurodegenerative disorder, Parkinson disease (PD) is classically characterized by fine resting tremor, cogwheeling rigidity, akinesia and mask-like facies, and postural instability. Comorbidity of psychiatric disorders is high, both as a result of the underlying disease process and as a side effect of dopaminergic treatment regimes. Common presentations of psychiatric disorders in PD include schizophrenia-like psychosis with visual hallucinations and mood disorders with prominent apathy and executive dysfunction. Recognition of the comorbidity is important because psychiatric disorders in PD respond differently to treatment than classic psychiatric disorders.24
Temporal Lobe Epilepsy
Epilepsy is a complex group of related neurological disorders involving unregulated nerve cell firing with a large variability in clinical presentation. Characteristically there is recurrent seizure activity. Temporal lobe epilepsy (TLE) is a subset of epilepsy known to present as a number of behavioral and neuropsychiatric complaints. Most presentations of TLE involve auras of emotional phenomena such as depression, fear, or anxiety, which can occur alone or with subsequent progression to complex partial or secondary generalized seizures.25 Many other bizarre presentations of TLE have been reported, including recurrent, potentially debilitating déjà vu, vivid recollection of past traumatic events mimicking posttraumatic stress disorder, paranoid delusions following olfactory triggers; and unprovoked attacks of depersonalization, derealization, anxiety, and dyspnea originally misdiagnosed as panic attack.
Stroke
The term “stroke chameleon” refers to presentations suggestive of other diseases that actually represent underlying strokes. Altered mental status is by far the largest block of these chameleons, with up to 30% of misdiagnosed strokes being misdiagnosed as altered mental status. The positive predictive value of altered mental status alone (ie, the chance that the diagnosis of altered mental status actually represents an undiagnosed acute stroke) is 7%.26
Case Scenarios Continued
Case 1
[The 58-year-old woman with intermittent chest pain.]
The patient’s D-dimer and troponin I levels were normal. Before the EP had an opportunity to discuss the results and next steps with the patient, the nurse asked him to see the patient immediately. Upon entering her room, the EP noted that the patient appeared anxious. The patient said the shortness of breath had returned, and also that she felt as if she were “floating” off the gurney, outside of her body. A check of her vital signs revealed a heart rate of 106 beats/minute and blood pressure of 160/100 mm Hg. A repeat ECG was significant only for sinus tachycardia. In an effort to calm the patient, the EP reassured her that the ECG, chest X-ray, and screening laboratory studies were normal, and that there was no evidence of a heart attack. Relieved, the patient asked for an Ativan to calm her nerves. Upon further questioning, the patient sheepishly reported that she had been taking 3 to 6 mg lorazepam for about 10 years, as prescribed by her family physician (FP) for anxiety. She further admitted that she abruptly discontinued taking the drug about one week before this ED visit after she’d heard on a daytime TV show that the medication was addictive.