Psychosis: medical causes

Today we discussed the approach to the psychotic patient from a medical standpoint (i.e. causes other than primary psychiatric disease)

See this post for a general approach to dementia.

In terms of psychosis (i.e. hallucinations or delusions) from a medical cause, things to think about include:

Delirium
Hallmark is attention problems. Also cognitive problems, simple hallucinations (often visual), fluctuating course, underlying medical condition
General causes:
Infection, intoxication (esp. anticholinergic; 'mad as a hatter'), medications (e.g. benzos, opiates), substance withdrawal (esp. alcohol), metabolic derangements (Na, Ca, hepatic encephalopathy, uremia), trauma, CNS pathology, hypoxia, deficiencies, endocrine (e.g. hyper or hypothyroidism, hypoglycemia), vascular (e.g. vasculitis, hypertensive emergencies)

With more elaborate hallucinations/delusions, other medical possibilities that are well known to present with psychosis include
-Seizures (especially temporal lobe)
-Encephalitis (especially HSV encephalitis)
-Brain tumor / bleed involving the temporal lobe
-Lewy Body dementia (classically non-bizzare delusions, worsens with neuroleptics)
-Neurosyphillis
-Wilson's disease
-Hyperthyroidism
-Neuropsychiatric lupus
-Carbon monoxide poisoning
-Charles Bonnet syndrome
(complex visual hallucinations with insight in pts with visual impairment that reverse with visual correction)
-"megaloblastic madness" from B12 or folate deficiency
-Porphyria

Link:
Click here for a summary of medical causes of psychosis to consider.

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