Although the emergency physician (EP) typically encounters common conditions such as chest pain, urinary tract infection, and gastroenteritis, many other clinical presentations can confound diagnosis of the true underlying condition. This may be the case with a patient who presents with apparent psychiatric symptoms that are actually masking an acute medical condition. For example, a patient who appears to be depressed may actually be exhibiting early signs of dementia. Likewise, a manic patient may not have a true underlying psychiatric disorder but rather rhabdomyolysis and hyperthermia from ingesting an illicit substance such as synthetic cathinones (“bath salts”).
Part 1 of this series reviewed psychiatric presentations caused by underlying infectious, pharmacological withdrawal, metabolic, autoimmune, traumatic, and central nervous system etiologies (Emerg Med. 2016;48[5]:202-211). Part 2 covers psychiatric presentations related to dementia, cancer, cardiac disease, nutritional deficiencies, endocrine disorders, or toxins (Table 1).
Case Scenarios
Case 1
A 62-year-old man with a history of hypertension, hyperlipidemia, and past alcohol abuse presented to the ED with reported mental status changes after he was pulled over by police for driving the wrong way down the highway. On presentation, the patient’s vital signs were normal. When questioned, the patient was alert and fully oriented and believed the officers were mistaken about what was reported. He denied any recent illness and had a normal physical examination, including neurological examination.
A brief work-up was ordered and the patient passed the time by politely flirting with the nurses. When his wife arrived at the ED, she was relieved that her husband seemed to be all right. She confirmed that the patient had not consumed any alcohol in years. The patient, meanwhile, playfully minimized his wife’s concern at his presence in the ED. A full toxicology screen, laboratory evaluation, and head computed tomography (CT) scan were ordered.
Case 2
A 48-year-old woman with a history of anxiety disorder, depression, and diabetes mellitus presented to the ED with a 2-hour history of chest pain. She stated that the pain had started toward the end of a heated argument with her son. The patient was escorted into the examination room by hospital security because she was still agitated and kept yelling at her son. On examination the patient was tachycardic (110 beats/minute), diaphoretic, and crying. During the examination, she asked the EP for a “Xanax”; her son further noted that this would help his mother’s condition.
The patient repeatedly claimed she could not breathe and could not lie flat on the stretcher. After verbal de-escalation, she cooperated with the electrocardiography (ECG) technician and phlebotomist. Her ECG showed nonspecific ST changes with no prior study for comparison. While glaring at her son, she maintained that she had constant chest pain.
Dementia
Alzheimer’s Disease
Alzheimer’s disease (AD), the most common cause of dementia, is a chronic neurodegenerative disease characterized by an insidiously progressive cognitive decline and loss of function. There is considerable apparent variability in the early signs of the disease, and recent literature has suggested that the manifestation of initial symptoms may be age-dependent. Younger patients tend to present with non-memory cognitive changes such as problem-solving difficulties, as well as personality changes and behavioral symptoms of depression, apathy, and withdrawal.1
Lewy Body Dementia
Lewy body dementia (LBD) is a chronic neurodegenerative disease with a presentation that overlaps substantially with AD. However, LBD is associated with a significantly more rapid course than AD and presents more frequently with visual hallucinations or illusions due to specific visuospatial dysfunction.2
Frontotemporal Dementia
Frontotemporal dementia is a comparatively rare chronic neurodegenerative disease characterized by early-onset memory impairment with cognitive decline, as well as behavioral changes such as disinhibition, emotional blunting, and language difficulty. Initial presentations can also include atypical features such as paranoia or delusion, and misdiagnosis as a primary psychiatric problem is common.3
Cancer
Brain Tumor
Primary and metastatic brain tumors classically present with either focal neurological signs or less specific symptoms such as headaches, seizures, or syncope. Additionally, central nervous system (CNS) tumors can also initially present with primary psychiatric complaints (eg, personality changes, depression, mania, panic attacks, auditory or visual hallucinations). Patients with a brain neoplasm who are initially misdiagnosed with a primary psychiatric disorder face significant delays in proper diagnosis and treatment, leading to increased morbidity. To correctly diagnose the true cause as soon as possible, early imaging is recommended for patients who present with psychiatric symptoms that are abrupt in onset, atypical in presentation, resistant to conventional treatments, or associated with a change in headache pattern.4