Primary & Secondary psychiatric disorders

Primary VS Secondary Psychiatric Disorders

Etiology: one diagnosable (flare up of systemic medical disease, CNS disease or substance).
- e.g. Depression due to SLE
- Psychosis due to amphetamine
In medicine: like secondary HTN due to renal artery stenosis.
Clues suggestive of being secondary:
- Disturbance of consciousness or vital signs
- Presence of:
  - ❏ non-auditory hallucinations e.g. visual,
  - ❏ hard neurological signs
  - ❏ physical illness
  - ❏ old age onset

Etiology: Multi-factorial
- e.g. Schizophrenia
- Major depressive disorder
In medicine: like Essential hypertension.
Clues suggestive of being primary:
- Normal consciousness & vital signs.
- Presence of:
  - ❏ Auditory hallucinations
  - ❏ soft neurological signs
  - ❏ Young age onset

Endocrine
- Thyroid disorder
  - Hypo-
  - Hyper-
- Adrenal disorder
  - Hypo-
  - Hyper
- Pheochromocytoma
- Parathyroid DO
  - Hypo-
  - Hyper
- Pancreatic DO
  - Hyperglycemia
  - Hypoglycemia
  - Pancreatic tumor
Metabolic
- Hepatic disorder
- Wilson’s
- Encephalopathy
- Porphyria
- Vitamin def
  - B-1
  - B-12
- Electrolyte imbalances
- Hypoxia
- Lead toxicity
Infectious
- Neurocysticercosis
- Tuberculosis (TB)
- PANDA
- Neuroborreliosis
- Neurosyphilis
- Herpes
- HIV
- Sepsis
- Malaria
- Legionnaire disease
- Typhoid
- Diphtheria
- Rheumatic fever
- UTI
Autoimmune
- Systemic Lupus Erythematosus
- Multiple Sclerosis
- Pernicious Anemia (B12 def)
- Addison’s Disease (hypoadrenalism)
- Grave’s Disease (hyperthyroidism)
- Fibromyalgia
- PANDA
CNS
- Seizure DO
- TLE
- Frontal LE
- Paraneoplastic Syndrome
- Dementia
- NPH
- Delirium
- Subdural hematoma
- Tumor
- Meningitis
- Encephalitis
- Multiple Sclerosis
- NMS

Prescription drugs
- Chemotherapeutic Rx’s
- Immunosuppressants (e.g., cyclosporin [Gengraf, Neoral, Sandimmune])
- Antiviral Rx’s (e.g., interferons)
- Antiparkinsonian Rx’s
- Cardiovascular Rx’s
- Thyroid Rx’s
- Anticholinergic Rx’s
- Corticosteroids
- Psychostimulants
- Sympathomimetics
- Sedative & CNS-depressants (e.g., barbiturates, benzodiazepines)
- Opioids

Psychological symptoms occurring …
- New onset psychiatric symptoms presenting after age 40.
- During the course of a major medical illness which had impaired some organ function (e.g., neurological, endocrine, renal, hepatic, cardiac, pulmonary).
- While taking medications/illicit substance, he had psychoactive effects.
Family history of:
- -ve for primary psychiatric illness..
- +ve for medical disease that may present with psychiatric symptoms e.g.:
  - Degenerative or inheritable neurological disorders
    - (e.g., Alzheimer’s disease, Huntington’s disease)
  - Inheritable metabolic disorders (e.g., DM, Pernicious Anemia, Porphyria)

Abnormal vital signs.
Evidence of organ dysfunction, focal neurological deficits.
Eye exam:
- Pupillary changes—asymmetries
- Nystagmus (often a sign of drug intoxication)
Presence of altered states of mind, LOC, mental status changes, cognitive impairment; episodic, recurrent, cyclic course
Presence of visual, tactile or olfactory hallucinations
Signs of:
- Cortical dysfunction (e.g., dysphagia, apraxia, agnosia)
- Diffuse subcortical dysfunction (e.g., slowed speech/mentation/movement, ataxia, incoordination, tremor, chorea, asterixis, dysarthria)