Physical illness manifesting as psychiatric disease. II. Analysis of a state hospital inpatient population.

One hundred patients of lower socioeconomic class were intensively evaluated medically on a research ward for the presence of unrecognized medical illnesses that might have affected their hospitalization. Forty-six percent were thought to have medical illnesses that directly caused or greatly exacerbated their symptoms and were consequently responsible for their admission, while an additional 34% of patients were found to be suffering from a medical illness requiring treatment. A diagnostic battery of physical, psychiatric, and neurologic examinations, coupled with a 34-panel automated blood analysis, complete blood cell count, urinanalysis, ECG, and sleep-deprived EEG established the presence and nature of more than 90% of the illnesses detected, and is therefore recommended as an initial evaluation battery, particularly for patients facing involuntary commitment to a mental hospital.

Physical illness presenting as psychiatric disease.

A study of 658 consecutive psychiatric outpatients receiving careful medical and biochemical evaluation, defined an incidence of medical disorders productive of psychiatric symptoms in 9.1% of cases. The most frequent presentations were of depression, confusion, anxiety, and speech or memory disorders. The presence of visual hallucinations was believed to indicate medical etiology until proved otherwise. Major illnesses presenting with psychiatric symptoms in order of frequency were infectious, pulmonary, thyroid, diabetic, hematopoietic, hepatic and CNS diseases. Forty-six percent of these patients suffered from medical illnesses previously unknown to either them or their physician. A plea is made for careful medical evaluation of psychiatric patients.

Unrecognized physical illness prompting psychiatric admission: a prospective study.

The authors studied 100 state hospital psychiatric patients consecutively admitted to a research ward who were screened to eliminate physical illness before admission. They found an unusually high incidence of medical illness: 46% of these patients had an unrecognized medical illness that either caused or exacerbated their psychiatric illness, 80% had physical illnesses requiring treatment, and 4% had precancerous conditions or illnesses. A workup consisting of psychiatric and physical examination, SMA-34, urinalysis, ECG, and EEG after sleep deprivation identified over 90% of medical illnesses present in this population. The authors suggest that such a battery be part of the routine workup for all hospitalized psychiatric patients.

Psychological aspects of long-term home hyperalimentation.

Ten patients (24--66 yr), maintained on ambulatory home intravenous hyperalimentation (HIVH) for 1/2--3 1/4 years, have undergone psychological evaluation. Acceptance of oral deprivation and the inconveniences, restraints, and risks of long-term or life-long HIVH, and the mechanisms for coping with these stresses, varied among this group. At times, the fear related to the HIVH apparatus and its function assumed almost delusional proportions; at other times, the patients acted indifferently or even irresponsibly toward the management of their life-sustaining system. These patients had to cope with public inquisitiveness as well as their own self-consciousness in public. Stress seemed to be related to the patient's prognosis, not only regarding recovery from the primary pathologic process, but also his/her prospects for return of normal gastrointestinal function. Stress reactions also varied among the spouses and families of the patients, and the quality of their psychological support appeared to affect the patient's mental, physical, and social wellbeing significantly. An entirely new spectrum of psychologic and social problems have emerged to challenge the IVH team who successfully manage patients unable to sustain themselves nutritionally. It is imperative that we recognize, prevent, ameliorate, and treat these problems with the same degree of enthusiasm and competence with which we nourish the patients.

The effect of referral procedures on aftercare compliance.

A study of four referral procedures involving 400 patients discharged consecutively from a geographically distant state hospital and referred to a community mental health center for aftercare suggests that simple changes in hospital discharge systems can increase compliance of patients and reduce recidivism. The scheduling of a specific follow-up appointment for the patient increased aftercare compliance significantly. Compliance was further increased, and the recidivism rate was cut in half, when the patient was seen by the community mental health aftercare nurse before discharge and was also given a specific follow-up appointment with that nurse.

Presentation of the steroid psychoses.

This study suggests that patients receiving daily doses of 40 mg of prednisone or its equivalent, are at greater risk for developing steroid psychosis. Psychotic reactions were twice as likely to occur during the first 5 days of treatment as subsequently. Premorbid personality, history of previous psychiatric disorder, and a history of previous steroid psychosis did not clearly increase the patient's risk of developing psychotic reaction during any given course of therapy. Steroid psychoses present as spectrum psychoses with symptoms ranging from affective through schizophreniform to those of an organic brain syndrome. No characteristic stable presentation was observed in these 14 cases reported here. The most prominent symptom constellation to appear some time during the course of the illness consisted of emotional lability, anxiety, distractibility, pressured speech, sensory flooding, insomnia, depression, perplexity, agitation, auditory and visual hallucinations, intermittent memory impairment, mutism, disturbances of body image, delusions, apathy, and hypomania. Phenothiazines administered in average daily doses of 212 mg produced excellent response in all patients studied. Of particular note was the fact that tricyclic antidepressants produced an exacerbation or worsening of the clinical state in all patients to whom they were administered.

Covert outpatient drug abuse. Incidence and therapist recognition.

One hundred ninety-five consecutive psychiatric outpatients were surveyed for covert drug abuse by a standardized technique for determining opiates, cocaine, barbiturates, and amphetamines in urine samples. On the basis of demographic variables, diagnostic information, and treatment course, patterns of abuse were defined for the 13.3 per cent with positive test results. Covert abusers demonstrated a higher incidence of adverse drug reactions and a less favorable therapy course than controls. Covert abuse was meaningfuly related to misdiagnosis, management problems, and therapist's response. Demographic variables and patient reports of previous abuse were not found to be reliable predicators of covert drug abuse. Urine screening for drug use is recommended as an aid to proper diagnosis of psychiatric outpatients that present diagnostic questions.

The effect of unrecognized drug abuse on diagnosis and therapeutic outcome.

One-hundred and ninety-five consecutive psychiatric outpatients had urine sampled for the presence of opiates, cocaine, barbiturates, and amphetamines. All patients had demographic variables, diagnostic information, and treatment course analyzed in a blind fashion using preselected criteria. Patterns of abuse were defined for the 13.3% of the total sample who were covert abusers. An analysis of diagnostic accuracy for abusing and nonabusing populations indicated that covert abuse markedly distorted diagnosis and management. The study indicates that demographic variables and previous history were not reliable predicators of covert abuse. Drug abuse was a major factor in distorting the accuracy of diagnosis. Drug abusers were significantly less likely to improve with therapy than were nonabusers. Barbiturate abusers were most likely to suffer from adverse drug reactions. Urine screening for drugs was the single most valuable diagnostic tool and was felt to be indicated in all cases where diagnostic confusion was present. Therapists saw the covert abuser as sick out of proportion to their social behavior, were perplexed and frightened by these patients' dependency, and perceived them as too brittle for therapy. Therapists behaved very differently with these patients than with diagnostically matched controls. They misdiagnosed them four times more often, missed appointments with them seven times more often, and were ten times more likely to refer them to another therapist or agency. Therapist anxiety and "flight from therapy" with covertly abusing patients are discussed.