Distinguishing the cause of a patient’s psychotic symptoms can be clinically challenging in a primary care practice. This case was submitted by Matthew Rosenberg, MD, who practices family medicine at Sacramento (CA) County Primary Care Clinic. This month’s consultant is Bezalel Dantz, MD.
How would you have advised Dr. Rosenberg?
Case: ‘you’re just gonna die’
I was seeing Mr. J, age 31, weekly to monitor abdominal complaints. For 3 weeks he experienced increasing epigastric pain, and he had been evaluated twice in the emergency room for this complaint. Plain films, ultrasound, CT, and an elevated lipase reading suggested an inconclusive diagnosis of pancreatitis.
During his second office visit, Mr. J also complained of “hearing voices.” Further questioning revealed that he had been hearing voices—often male—making degrading comments for several years. The voices have increased in frequency during his illness, and their negative comments include, “What do you have to live for?” and “You’re just gonna die.”
Mr. J blames the voices on distant drug use, claiming his parents “forced” him as a young teen to take hallucinogens. He often thinks he is being followed and does not trust others. He said both parents had mental illnesses but does not know the diagnoses or seriousness of their disorders.
His thoughts are well-organized with clear content. He shows no signs of depression or mania. He plays guitar in a band and appears to be a thoughtful and high-functioning individual.
I need help with the differential diagnosis and suggestions of possible treatment options.
Dr. Dantz’s consultation
The first step in evaluating psychosis is to determine whether it indicates a medical disorder, substanceinduced disorder, or primary psychiatric illness. The chronicity and nature of Mr. J’s psychotic symptoms (auditory hallucinations and paranoid delusions), his age, and a family history of psychiatric illness suggest a primary psychiatric disorder. The elevated lipase might explain his abdominal pain but is likely independent of his psychosis.
Medical workup. Conduct a comprehensive physical exam and medical and psychiatric history. Obtain collateral information from the family about the patient’s psychiatric symptoms, family history, recreational drug use, and stressors. Acute onset, age >40, comorbid medical conditions, lack of acute psychosocial stressors, and a negative personal or family psychiatric history suggest a medical cause (The skinny on one patient’s psychosis,” November 2005.) Also assess for use of alcohol, marijuana, hallucinogens, narcotics, stimulants, and inhalants. Until any drug has been stopped for at least 1 week, its contribution to psychosis may be unclear.
Table 1
Medical conditions that may present as psychosis
| Type of condition | Examples |
|---|---|
| CNS infection | HIV, neurosyphilis, cycticercosis, encephalitis, prion disease |
| Neoplasm | Primary or metastatic, paraneoplastic syndromes |
| Endocrinopathies | Thyroid, parathyroid, adrenal |
| Degenerative diseases | Alzheimer’s disease, frontotemporal dementia, Huntington’s disease, Parkinson’s disease, Wilson’s disease, Lewy body dementia |
| Demyelinating disorders | Multiple sclerosis, adrenal leukodystrophy |
| Metabolic disorders | Cirrhosis, vitamin deficiency, uremia, porphyria, heavy metal poisoning |
| Vasculitis | Systemic lupus erythematosus |
| Others | Seizures, migraine aura, hypnagogic and hypnopompic hallucinations, neurosarcoidosis |
Lab testing. When signs or symptoms do not suggest an organic disease, laboratory tests have a low yield and are of questionable value.2 In primary care practice, however, many psychotic patients complain of somatic symptoms. Given the devastating impact of psychotic illness, one can argue that even a yield <5% justifies a workup.
A urine toxicology screen is by far the most important lab test. CBC, comprehensive metabolic panel, thyroid function tests, erythrocyte sedimentation rate, and calcium level may reveal a medical cause. Consider HIV antibody and syphilis tests in at-risk individuals.
Findings on physical exam or abnormal lab results would guide further testing. Because of Mr. J’s GI and neurologic symptoms, a 24-hour urine test may be reasonable, particularly if he has had episodes of acute intermittent porphyria.
Neuroimaging. Consider a scan when psychosis is comorbid with:
- age >40
- neurologic complaints (such as headache, numbness, vertigo, seizures)
- focal neurologic findings (such as weakness, gait abnormality, clonus, or spasticity)
- confusion, cognitive deficit, history of malignancy
- head trauma
- immunocompromised state
- atypical psychotic symptoms (such as visual or olfactory hallucinations).
Psychiatric workup. If the history and physical exam reveal no organic basis, the next step is to determine the nature of this patient’s psychosis. The two most common psychiatric conditions associated with psychosis are:
- schizophrenic spectrum disorders (such as schizophreniform, schizophrenia and schizoaffective disorder)
- affective disorders (such as psychotic depression and bipolar disorder).
Distinguishing among these conditions can be challenging (Table 2) because patients rarely present with typical syndromes.
For example, a bipolar patient may present in a mixed state with both depressive and manic features. Psychosis in schizophrenia may be brief (<6 months in schizophreniform disorder) and may be characterized by manic-like grandiose delusions or negative symptoms (flat affect, poverty of speech) that mimic affective symptoms. Finally, some patients have both an affective disorder and schizophrenia, as in schizoaffective disorder.