European Review for Medical and Pharmacological Sciences 2013; 17(Suppl 1): 65-85 Psychiatric emergencies (part II): psychiatric disorders coexisting with organic diseases A. TESTA, R. GIANNUZZI, F. SOLLAZZO*, L. PETRONGOLO**, L. BERNARDINI**, S. DAINI** Department of Emergency Medicine, “A. Gemelli” Hospital, Catholic University of the Sacred Heart, Rome, Italy *Neuropsychiatric Pathology, Psychiatric Hospital “Parco dei Tigli”, Teolo (Padua), Italy **Department of Psychiatry and Psychology, “A. Gemelli” Hospital, Catholic University of the Sacred Heart, Rome, Italy Abstract. – BACKGROUND: In this Part II feine, modafinil), hallucinogens (mescaline, LSD, psychiatric disorders coexisting with organic ecstasy) and other substances (cannabis, disso- diseases are discussed. ciatives, inhalants). Anxiety disorders can occur in “Comorbidity phenomenon” defines the not intoxication by stimulants, as well as in withdrawal univocal interrelation between medical illnesses syndrome, both by stimulants and sedatives. Sub- and psychiatric disorders, each other negatively stance induced mood disorders and psychotic influencing morbidity and mortality. Most severe symptoms are as much frequent conditions in ED, psychiatric disorders, such as schizophrenia, and the recognition of associated organic symp- bipolar disorder and depression, show increased toms may allow to achieve diagnosis. Finally, psy- prevalence of cardiovascular disease, related to chiatric and organic symptoms may be caused by poverty, use of psychotropic medication, and prescription and doping medications, either as a higher rate of preventable risk factors such as direct effect or after withdrawal. Adverse drug reac- smoking, addiction, poor diet and lack of exercise. tions can be divided in type A, dose dependent and Moreover, psychiatric and organic disorders can predictable, including psychotropic drugs and hor- develop together in different conditions of toxic mones; and type B, dose independent and unpre- substance and prescription drug use or abuse, es- dictable, usually including non psychotropic pecially in the emergency setting population. Dif- drugs, more commonly included being cardiovas- ferent combinations with mutual interaction of psy- cular, antibiotics, anti-inflammatory and antineo- chiatric disorders and substance use disorders are plastic medications. defined by the so called “dual diagnosis”. The hy- potheses that attempt to explain the psychiatric Key Words: disorders and substance abuse relationship are Psychiatric emergencies, Anxiety disorders, Mood examined: (1) common risk factors; (2) psychiatric disorders, Psychosis, Comorbidity, Dual diagnosis, disorders precipitated by substance use; (3) psy- Substance abuse, Drug abuse, Substance addiction, chiatric disorders precipitating substance use Drug adverse reactions. (self-medication hypothesis); and (4) synergistic interaction. Diagnostic and therapeutic difficulty concerning the problem of dual diagnosis, and le- Abbreviations gal implications, are also discussed. ACE = angiotensin-converting enzyme Substance induced psychiatric and organic symptoms can occur both in the intoxication and ADHD = attention deficit hyperactivity disorder withdrawal state. Since ancient history, humans se- CNS = central nervous system lected indigene psychotropic plants for recreation- COPD = chronic obstructive pulmonary disease al, medicinal, doping or spiritual purpose. After the CNS = central nervous system isolation of active principles or their chemical syn- ECG = electrocardiogram thesis, higher blood concentrations reached pre- ED = emergency department dispose to substance use, abuse and dependence. EEG = electroencephalogram Abuse substances have specific molecular targets GABA = gamma amino butyric acid and very different acute mechanisms of action, GHB = gamma hydroxybutyrate mainly involving dopaminergic and serotoninergic GnRH = gonadotropin releasing hormone systems, but finally converging on the brain’s re- GCS = Glasgow coma scale ward pathways, increasing dopamine in nucleus HIV/AIDS = human immunodeficiency virus/acquired accumbens. The most common substances pro- immune-deficiency syndrome ducing an addiction status may be assembled in ICU = intensive care unit depressants (alcohol, benzodiazepines, opiates), IFN = interferon stimulants (cocaine, amphetamines, nicotine, caf- LSD = lysergic acid Corresponding Author: Americo Testa, MD; e-mail: [email protected] 65 A. Testa, R. Giannuzzi, F. Sollazzo, L. Petrongolo, L. Bernardini, S. Daini MAOI = momoamino oxidase inhibitor The patient with psychiatric disorder who MDMA = 3,4-methylenedioxy-N-methylamphetamine complains medical illness is disconcerted in re- MR = magnetic resonance lating his symptoms. Both the patient and the NMDA = N-methyl-D-aspartate (receptor) NRI = noradrenalin reuptake inhibitor physician have great effort in diagnosing them as NSAID = non steroidal anti-inflammatory drug “real” or “unreal” symptoms. Most psychiatric PTSD = post-traumatic stress disorder disorders, such as schizophrenia, bipolar disorder SNRI = selective serotonin/norepinephrine reuptake and depression, are associated with undue med- inhibitor ical morbidity and mortality. It represents a ma- SSRI = selective serotonin reuptake inhibitor jor health problem, with up to 30 year shorter THC = delta-9-tetrahydrocannabinol lifetime compared with the general population, VTA = ventral tegmental area primarily due to premature cardiovascular dis- ease. The causes of increased metabolic and car- Introduction diovascular disease in this population are strong- ly related to poverty and limited access to med- The independent coexistence of psychiatric ical care, but also to the use of psychotropic and organic disorders in the same patient results medication. Moreover, the patients with severe in the well known “comorbidity phenomenon”. It mental illness have a higher rate of preventable defines the controversial interrelation between risk factors such as smoking, addiction, poor diet psychiatric disorders and organic diseases, each and lack of exercise3. Anxiety and post-traumatic other negatively influencing morbidity and mor- stress disorder (PTSD) seem to be interrelated tality. Indeed, concurrent or lifetime comorbidity with heart diseases in quite a similar way, con- phenomenon ranges from casual occurrence of tributing even more negatively to critical cardio- psychiatric disorders and medical diseases, to the logic events than depression. The prevalence actual susceptibility of psychiatric patients to rates of depressive disorders in various cardiolog- contract organic diseases, and vice versa. ic conditions are significantly higher than the fre- Co-occurrence and mutual interaction of psychi- quencies that can be expected in healthy general atric disorders and/or medical illness and substance population4. A complex relationship is known or drug abuse may also develop, causing diagnostic even between psychiatric disorders and respira- and therapeutic difficulty and significant legal im- tory illnesses. Moreover, anxiety, depression and plications1. Therefore, findings can vary depending psychosis are considered significant causes of on factors such as type of psychiatric and organic morbidity and mortality in patients suffering disorders and substance involved, making it neces- from COPD and asthma. Within gastroenterolog- sary to differentiate whether clinical symptoms are ical diseases, mental illness and psychosomatic primary, independent, or substance-induced, thus disorders have a main role either in therapy man- transient and treatable. agement or in patients quality of life, through the disease perception and its symptoms. Psychiatric patients are at high risk even for hepatic illness- Co-morbidity of Psychiatric Disorders, es: because the diffuse substances abuse and ad- Medical Diseases and Substance Abuse diction, they are more exposed to alcohol dam- age and infections by hepatic viruses and HIV. Co-occurrence of Psychiatric Disorders There is evidence that the association of mellitus and Medical Diseases diabetes and psychosis makes worse the progno- An alternative approach to “categorial” classi- sis both of psychiatric disorder and the metabolic fication (DMS IV-TR and ICD-10) for definition disease. In the end, a mention deserves even an- of psychiatric disorders consists in the “dimen- tipsychotics because these drugs have a complex sional” approach. This is based on the possibility way of action and can manifest interactions with that many psychiatric disorders present in a other drugs employed in different internal dis- vague or episodic form, without satisfying the eases and cause different side effects5. criteria for “categorical” disorders (so called sub- Otherwise, a patient with severe medical ill- threshold disorders). The dimensional approach ness complaining psychiatric symptoms chal- allows to detect minor but clinically meaningful lenges in depicting their independent nature, or symptoms and adjust therapeutic approach, as in- attributing a reactive significance (somatopsychic tegration of pharmacological and psycho-social disorders), or recognizing the occurrence of drug approach, in proportion to its relevance2. side effects. Emergence anxiety, depression, 66 Psychiatric emergencies (part II): psychiatric disorders coexisting with organic diseases delirium and other acute psychotic manifesta- Etiopathogenetic Mechanisms tions affecting postoperative and ICU patients, Several hypotheses have been advanced to ex- cancer and