Neuropsychiatric Manifestations of Systemic Medical Conditions

  • Mariam Abdurrahman


Systemic medical conditions frequently present with neuropsychiatric symptomatology that may be misattributed to a primary psychiatric disturbance. A broad spectrum of systemic medical conditions can mimic primary neuropsychiatric processes. The most common medical mimics include autoimmune, endocrine, infectious, metabolic, iatrogenic, and neoplastic processes. These processes occur at a higher frequency in the geriatric population. Thus, in evaluating older adults presenting with neuropsychiatric symptoms, a wide differential diagnosis is required in order to avoid incorrect and potentially dangerous attribution to primary psychiatric disorders as the chief cause of the presentation. There are no pathognomonic signs or symptoms that reliably indicate a systemic medical condition versus a psychiatric disorder. In addition, robust presentations that are typically described as “classic” features of a number of common systemic medical disorders are less likely to be seen in older adults; thus it is imperative to ensure a careful workup to rule out an underlying or contributory medical condition. Involvement of colleagues from appropriate medical specialities is essential to timely and appropriate workup and management of patients with atypical, seemingly treatment-refractory, or progressive neuropsychiatric symptomatology.


Autoimmune Endocrinopathy General medical condition Medical mimic(s) Mimicry Neuropsychiatric manifestations Neuropsychiatric symptoms Secondary neuropsychiatric symptoms 


  1. 1.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Arlington: American Psychiatric Publishing; 2000.Google Scholar
  2. 2.
    Cutting J. The phenomenology of acute organic psychosis. Comparison with acute schizophrenia. Br J Psychiatry. 1987;151:324–32.CrossRefPubMedGoogle Scholar
  3. 3.
    Freudenreich O. Differential diagnosis of psychotic symptoms: medical “mimics”. Psychiatric Times. 2012. Accessed 12 Sept 2016.
  4. 4.
    Isaac ML, Larson EB. Medical conditions with neuropsychiatric manifestations. Med Clin N Am. 2014:98, 1193–1208.
  5. 5.
    Tango RC. Psychiatric side effects of medications prescribed in internal medicine. Dialogues Clin Neurosci. 2003;5(2):155–65.Google Scholar
  6. 6.
    Sutor B, Rumans TA, Lapid MI. Atypical neuropsychiatric symptoms in the elderly. Ann Longterm Care. 2006;14(6):40–5.Google Scholar
  7. 7.
    Andrès E, Loukili NH, Noel E, Kaltenbach G, Abdelgheni MB, Perrin AE, Noblet-Dick M, Maloisel F, Schlienger JL, Blicklé JF. Vitamin B12 (cobalamin) deficiency in elderly patients. CMAJ. 2004;171(3):251–9. Review.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Lachner C, Steinle I, Regenold WT. The neuropsychiatry of vitamin B12 deficiency in elderly patients. J Neuropsychiatr Clin Neurosci. 2012;24(1):5–14.CrossRefGoogle Scholar
  9. 9.
    Mak A, Ho RCM, Lau CS. Clinical implications of neuropsychiatric systemic lupus erythematosus. Adv Psychiatr Treat. 2009;15:451–8.CrossRefGoogle Scholar
  10. 10.
    SouthernCare University. Atypical presentation of disease in the elderly. SCU Continuing Education; 2013.,%20SW,%20CHAP%20-%203.14.13.pdf. Accessed 12 Aug 2016.
  11. 11.
    Meagher DJ, Moran M, Raju B, et al. Phenomenology of delirium. Assessment of 100 adult cases using standardised measures. Br J Psychiatry. 2007;190:135–41.CrossRefPubMedGoogle Scholar
  12. 12.
    Webster R, Holroyd S. Prevalence of psychotic symptoms in delirium. Psychosomatics. 2000;41:519–22.CrossRefPubMedGoogle Scholar
  13. 13.
    Ur Rehman H, Qazi S. Atypical manifestations of medical conditions in the elderly. CGS J CME. 2013;3:18–25.Google Scholar
  14. 14.
    Borchers AT, Naguwa SM, Shoenfeld Y, Gershwin ME. The geoepidemiology of systemic lupus erythematosus. Autoimmun Rev. 2010;9:A277–87.CrossRefPubMedGoogle Scholar
  15. 15.
    Elkon K. Neuropsychiatric systemic lupus erythematosus. 2012. Accessed 16 Sept 2016.
  16. 16.
    Kivity S, Agmon-Levin N, Zandman-Goddard G, Chapman J, Shoenfeld Y. Neuropsychiatric lupus: a mosaic of clinical presentations. BMC Med. 2015;13:43. Scholar
  17. 17.
    Magro-Checa C, Zirkzee EJ, Huizinga TW, Steup-Beekman GM. Management of neuropsychiatric systemic lupus erythematosus: current approaches and future perspectives. Drugs. 2016;76(4):459–83. Scholar
  18. 18.
    Egner J. The use of laboratory tests in the diagnosis of SLE. J Clin Pathol. 2000;53:424–32.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    ACR Ad Hoc Committee on Neuropsychiatric Lupus Nomenclature. The American College of Rheumatology nomenclature and case definitions for neuropsychiatric lupus syndromes. Arthritis Rheum. 1999;42:599–608.CrossRefGoogle Scholar
  20. 20.
    Petri M, Orbai AM, Alarcón GS, et al. Derivation and validation of the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus. Arthritis Rheum. 2012;64(8):2677–86.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Appenzeller S, Cendes F, Castallat L. Acute psychosis in systemic lupus erythematosus. Rheumatol Int. 2008;28:237–43.CrossRefPubMedGoogle Scholar
  22. 22.
    Kershner P, Wang-Cheng R. Psychiatric side effects of steroid therapy. Psychosomatics. 1989;30:135–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Andrès E, Kaltenbach G, Perrin AE, Kurtz JE, Schlienger JL. Food-cobalamin malabsorption in the elderly. Am J Med. 2002;113:351–2.CrossRefPubMedGoogle Scholar
  24. 24.
    Carmel R, Gott PS, Waters CH, Cairo K, Green R, Bondareff W, DeGiorgio CM, Cummings JL, Jacobsen DW, Buckwalter G, et al. The frequently low cobalamin levels in dementia usually signify treatable metabolic, neurologic and electrophysiologic abnormalities. Eur J Haematol. 1995;54(4):245–53.CrossRefPubMedGoogle Scholar
  25. 25.
    Stabler SP. Vitamin B12 deficiency. N Engl J Med. 2013;368:149–60.CrossRefPubMedGoogle Scholar
  26. 26.
    Fauci AS, Isselbacher KJ, Wilson JD, et al. Harrison’s principles of internal medicine. 14th ed. New York: McGraw-Hill; 1998.Google Scholar
  27. 27.
    Maiti A, Chatterjee S. Neuropsychiatric manifestations and their outcomes in chronic hypocalcaemia. J Indian Med Assoc. 2013;111(3):174–7.PubMedGoogle Scholar
  28. 28.
    Watson LC, Marx CE. New onset of neuropsychiatric symptoms in the elderly: possible primary hyperparathyroidism. Psychosomatics. 2002;43(5):413–7.CrossRefPubMedGoogle Scholar
  29. 29.
  30. 30.
    Marsh CM. Psychiatric presentations of medical illness. Psychiatr Clin N Am. 1997;20(1):181–204.CrossRefGoogle Scholar
  31. 31.
    Mattei PL, Beachkofsky TM, Gilson RT, Wisco OJ. Syphilis: a reemerging infection. Am Fam Physician. 2012;86(5):433–40.PubMedGoogle Scholar
  32. 32.
    Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2012. Atlanta: U.S. Department of Health and Human Services; 2013.Google Scholar
  33. 33.
    Kirk JB, Goetz MB. Human immunodeficiency virus in an aging population, a complication of success. J Am Geriatr Soc. 2009;57(11):2129–38. Scholar
  34. 34.
    Simone MJ, Appelbaum J. HIV in older adults. Geriatrics. 2008;63(12):6–12.PubMedGoogle Scholar
  35. 35.
    Carvalhal A, J-G Baril F, Crouzat F, et al. Recognizing cognitive and psychiatric changes in the post-highly active antiretroviral therapy era. Can J Infect Dis Med Microbiol. 2012;23(4):209–15.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Ciesla JA, Roberts JE. Meta-analysis of the relationship between HIV infection and risk for depressive disorders. Am J Psychiatry. 2001;158:725–30.CrossRefPubMedGoogle Scholar
  37. 37.
    Arendt G. Affective disorders in patients with HIV infection. CNS Drugs. 2006;20:507–18.CrossRefPubMedGoogle Scholar
  38. 38.
    The Mind Exchange Working Group. Assessment, diagnosis, and treatment of HIV-associated neurocognitive disorder: a consensus report of the mind exchange program. Clin Infect Dis. 2013;56(7):1004–17.CrossRefGoogle Scholar
  39. 39.
    Heaton RK, Franklin DR, Ellis RJ, et al. HIV-associated neurocognitive disorders before and during the era of combination antiretroviral therapy: differences in rates, nature, and predictors. J Neurovirol. 2011;17:3–16.CrossRefPubMedGoogle Scholar
  40. 40.
    McDaniel JS, Purcell DW, Farber EW. Severe mental illness and HIV-related medical and neuropsychiatric sequelae. Clin Psychol Rev. 1997;17(3):311–25.CrossRefPubMedGoogle Scholar
  41. 41.
    Foster AR, Caplan JP. Paraneoplastic limbic encephalitis. Psychosomatics. 2009;50:108–13.CrossRefPubMedGoogle Scholar
  42. 42.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Publishing; 2013.CrossRefGoogle Scholar
  43. 43.
    Anantharaju A, Feller A, Chedid A. Aging liver. A review. Gerontology. 2002;48:343–35344. Unauthored. Pharmacokinetics in the Elderly. In: Merck Manual. 2016. Accessed 3 Oct 2016.CrossRefPubMedGoogle Scholar
  44. 44.
    Klotz U. Pharmacokinetics and drug metabolism in the elderly. Drug Metab Rev. 2009;41(2):67–76.Google Scholar
  45. 45.
    Cieslak KP, Baur O, Verheij J, Bennink RJ, van Gulik TM. Liver function declines with increasing age. HPB (Oxford). 2016;18(8):691–6.CrossRefGoogle Scholar
  46. 46.
    Toledano P, Sarbu N, Espinosa G, Bargallo N, Cervera R. Neuropsychiatric systemic lupus erythematosus: magnetic resonance imaging findings and correlation with clinical and immunological features. Autoimmun Rev. 2013;12:1166–70.CrossRefPubMedGoogle Scholar
  47. 47.
    Jeong HW, Her M, Bae JS, Kim SK, Lee SW, Kim HK, et al. Brain MRI in neuropsychiatric lupus: associations with the 1999 ACR case definitions. Rheumatol Int. 2015;35(5):861–9. CrossRefPubMedGoogle Scholar

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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.St. Joseph’s Health CentreTorontoCanada

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