Masquerading Symptoms: Uncovering Physical Illnesses That Present as Psychological Problems

Contents

Introduction

List of Diseases by Organ System or Disease Process

Part I: Signs and Symptoms

State of Consciousness

Clinical Significance

Clinical Observations

Delirium

Attention and Concentration

Clinical Significance

Clinical Observations

Mood, Affect, and Emotion

Clinical Significance

Clinical Observations

Notable Clinical Phenomena

Thought Form

Clinical Significance

Clinical Observations

Some Notable Clinical Phenomena

Thought Content and Experience of Reality

Clinical Significance

Clinical Observations

Notable Clinical Phenomena

Delusional Thought Content

Clinical Significance

Clinical Observations

Some Notable Clinical Phenomena

Hallucinations

Clinical Significance

Clinical Observations

Change in Personality or Behavior

Clinical Significance

Clinical Observations

Some Notable Clinical Phenomena

Judgment

Clinical Significance

Clinical Observations

Insight

Clinical Significance

Clinical Observations

Some Notable Clinical Phenomena

Dementia

Orientation

Clinical Significance

Clinical Observations

Some Notable Clinical Phenomena

Memory

Clinical Significance

Clinical Observations

Some Notable Clinical Phenomena

Speech and Language

Clinical Significance

Clinical Observations

Some Notable Clinical Phenomena

Other Cognitive Functions

Constructional Ability: Drawing, Copying, Visuospatial Tasks

Clinical Significance

Clinical Observations

Fund of Knowledge

Clinical Significance

Clinical Observations

Calculation

Clinical Significance

Clinical Observations

Abstract Thinking

Clinical Significance

Clinical Observations

Executive Functions

Clinical Significance

Clinical Observations

General Physical Appearance

Clinical Significance

Clinical Observations

Some Notable Clinical Phenomena

Motor Behavior

Clinical Significance

Clinical Observations

Some Notable Clinical Phenomena

Vegetative Symptoms

Disturbances of Sleep

Clinical Significance

Normal Sleep

Clinical Observations

Disturbances of Energy Level

Clinical Significance

Clinical Observations

Disturbances of Eating Behavior and Weight

Clinical Significance

Clinical Observations

Disturbances of Sexual Functioning

Clinical Significance

Clinical Observations

Notable Physical Symptoms and Possible Associated Diseases

Part II: The Diseases

Disease #1: Acromegaly

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Acromegaly?

Questions to Ask

Specialist Referral

Disease #2: Acute Intermittent Porphyria and Porphyria Variegata

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Porphyria?

Questions to Ask

Specialist Referral

Disease #3: Addison’s Disease

Primary Adrenal Insufficiency Secondary Adrenal Insufficiency

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Addison’s Disease? What Is Adrenal Insufficiency?

Questions to Ask

Specialist Referral

Disease #4: Alzheimer’s Disease

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Alzheimer’s Disease?

Questions to Ask

Specialist Referral

Disease #5: Arsenic Poisoning

Chronic Exposure to Low Levels of Arsenic Acute Exposure to High Levels of Arsenic

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Arsenic Poisoning?

Questions to Ask

Specialist Referral

Disease #6: Brain Tumors

Abscess in the Brain Cyst in the Brain Granuloma in the Brain

Possible Presenting Mental Signs and Symptoms

Possible Presenting Physical Signs and Symptoms

Other Symptoms Related to Specific Types of Lesions

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Are Brain Tumors and Other Solitary Brain Masses?

Questions to Ask

Specialist Referral

Disease #7: Carbon Monoxide Poisoning

Exposure to High Levels of Carbon Monoxide Chronic Exposure to Low Levels of Carbon Monoxide Late-Appearing Neuropsychological Symptoms Long-Term Disabilities from Carbon Monoxide Poisoning

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Carbon Monoxide Poisoning?

Questions to Ask

Specialist Referral

Disease #8: Charles Bonnet Syndrome

Disease #9: Chronic Subdural Hematoma

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is a Chronic Subdural Hematoma?

Questions to Ask

Specialist Referral

Disease #10: Chronic Traumatic Encephalopathy

Disease #11: Circadian Rhythm Disorders

Delayed Sleep Phase Syndrome Advanced Sleep Phase Syndrome Irregular Sleep/Wake Pattern (Free Running) Non-24-Hour Sleep/Wake Disorder

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Are Disorders of Circadian Rhythm?

Important Questions to Ask

Specialist Referral

Disease #12: Corticobasal Degeneration

Disease #13: Creutzfeldt-Jakob Disease

Transmissible Spongiform Encephalopathies

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Creutzfeldt-Jakob Disease?

Specialist Referral

Questions to Ask

Disease #14: Cushing’s Syndrome

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Cushing’s Syndrome?

Questions to Ask

Specialist Referral

Disease #15: Dementia with Lewy Bodies

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Dementia with Lewy Bodies?

Questions to Ask

Specialist Referral

Disease #16: Frontotemporal Dementia

Pick’s Disease Semantic Dementia Progressive Nonfluent Aphasia Frontotemporal Dementia with Motor Neuron Disease

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Frontotemporal Dementia?

Questions to Ask

Specialist Referral

Disease #17: Hashimoto’s Encephalopathy

Disease #18: Hepatic Encephalopathy

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Hepatic Encephalopathy?

Questions to Ask

Specialist Referral

Disease #19: HIV/AIDS (Infection with the Human Immunodeficiency Virus)

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is HIV/AIDS (Infection with Human Immunodeficiency Virus Disease)?

Questions to Ask

Specialist Referral

Disease #20: Huntington’s Disease

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Huntington’s Disease?

Questions to Ask

Specialist Referral

Disease #21: Hyperparathyroidism, Primary (Including Hypercalcemia)

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Primary Hyperparathyroidism?

Questions to Ask

Specialist Referral

Disease #22: Hypersomnia, Idiopathic

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

Questions to Ask

Specialist Referral

Disease #23: Hypersomnia, Recurrent

Kleine-Levin Syndrome Menstruation-Related Hypersomnia

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Hypersomnia?

Questions to Ask

Specialist Referral

Disease #24: Hyperthyroidism

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Hyperthyroidism?

Questions to Ask

Specialist Referral

Disease #25: Hyperventilation Syndrome

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Hyperventilation Syndrome?

Questions to Ask

Specialist Referral

Disease #26: Hypoglycemia

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Hypoglycemia?

Questions to Ask

Specialist Referral

Disease #27: Hypoparathyroidism (Hypocalcemia)

Possible Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Hypoparathyroidism?

Questions to Ask

Specialist Referral

Disease #28: Hypothyroidism

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Hypothyroidism?

Questions to Ask

Specialist Referral

Disease #29: Hypoxia (Insufficient Oxygen Supply to the Brain)

Hypoxic Brain Damage Altitude Sickness

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Hypoxia?

Questions to Ask

Specialist Referral

Disease #30: Lead Poisoning

Acute, High-Dose Exposure Low-Level, Chronic Exposure Subclinical Lead Poisoning

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Lead Poisoning?

Questions to Ask

Specialist Referral

Disease #31: Limbic Encephalitis

Viral Encephalitis Paraneoplastic Syndrome Autoimmune Encephalitis

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Limbic Encephalitis?

Questions to Ask

Specialist Referral

Disease #32: Lyme Disease

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Lyme Disease?

Questions to Ask

Specialist Referral

Disease #33: Manganese Toxicity

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Manganese Toxicity?

Questions to Ask

Specialist Referral

Disease #34: Mercury Poisoning

Acute, High-Dose Exposure Chronic, Low-Dose Exposure

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Mercury Poisoning?

Questions to Ask

Specialist Referral

Disease #35: Migraine

Headache Cluster Headaches

Possible Presenting Mental Signs and Symptoms

Presenting Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Are Migraine Headaches?

Questions to Ask

Specialist Referral

Disease #36: Mitochondrial Disorders

Specific Syndromes: Melas, Merrf, Lhon, Mngie, Kss, Narp, Leigh Syndrome

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is a Mitochondrial Disorder?

Questions to Ask

Specialist Referral

Disease #37: Multiple Sclerosis

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Multiple Sclerosis?

Questions to Ask

Specialist Referral

Onset

Trying to Work Normally

MS Confirmed

Disease #38: Multiple System Atrophy

Disease #39: Myasthenia Gravis

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Myasthenia Gravis?

Questions to Ask

Specialist Referral

Disease #40: Narcolepsy

Narcolepsy with Cataplexy Narcolepsy without Cataplexy Secondary Narcolepsy

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Narcolepsy?

Questions to Ask

Specialist Referral

Disease #41: Neuro-BehÇet’s Syndrome

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Neuro-Behçet’s Syndrome?

Questions to Ask

Specialist Referral

Disease #42: Neurofibromatosis Type

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Neurofibromatois?

Questions to Ask

Specialist Referral

Disease #43: Nocturnal Eating: Night-Eating Syndrome (NES)

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Night-Eating Syndrome?

Questions to Ask

Specialist Referral

Disease #44: Nocturnal Eating: Sleep-Related Eating Disorder (SRED)

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Sleep-Related Eating Disorder?

Questions to Ask

Specialist Referral

Disease #45: Normal-Pressure Hydrocephalus

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Normal-Pressure Hydrocephalus?

Specialist Referral

Questions to Ask

Disease #46: Pancreatic Cancer

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Pancreatic Cancer?

Specialist Referral

Disease #47: Parasomnias: Sleepwalking and Night Terrors

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Are the Parasomnias: Sleepwalking/Night Terrors?

Questions to Ask

Specialist Referral

Disease #48: Parkinson’s Disease

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Course and Prognosis

Prevalence and Population at Risk

What Is Parkinson’s Disease?

Questions to Ask

Specialist Referral

Disease #49: Partial Seizures

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Are Partial Seizures?

Questions to Ask

Specialist Referral

Disease #50: Pellagra

Nicotinic Acid Deficiency or Niacin Deficiency

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Pellagra?

Important Questions to Ask

Specialist Referral

Disease #51: Periodic Limb Movements of Sleep

Possible Presenting Mental Signs and Symptoms

Presenting Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Are Periodic Limb Movements of Sleep?

Questions to Ask

Specialist Referral

Disease #52: Pheochromocytoma

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is a Pheochromocytoma?

Questions to Ask

Specialist Referral

Disease #53: Postconcussion Syndrome

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Postconcussion Syndrome?

Questions to Ask

Specialist Referral

Disease #54: Premenstrual Dysphoric Disorder and Premenstrual Syndrome

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Are Premenstrual Dysphoric Disorder and Premenstrual Syndrome?

Questions to Ask

Specialist Referral

Disease #55: Primary Progressive Aphasia

Disease #56: Progressive Supranuclear Palsy

Disease #57: REM Sleep Behavior Disorder

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is REM Sleep Behavior Disorder?

Questions to Ask

Specialist Referral

Disease #58: Restless Legs Syndrome

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Restless Legs Syndrome?

Questions to Ask

Specialist Referral

Disease #59: Sleep Apnea

Obstructive Sleep Apnea

Central Sleep Apnea

Mixed Sleep Apnea

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Sleep Apnea?

Questions to Ask

Specialist Referral

Disease #60: Syphilis

General Paresis

Syphilitic Meningitis

Meningovascular Syphilis

Syphilitic Gummas

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Syphilis?

Questions to Ask

Specialist Referral

Disease #61: Systemic Lupus Erythematosus

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Systemic Lupus Erythematosus?

Questions to Ask

Specialist Referral

Disease #62: Thallium Poisoning

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Thallium Poisoning?

Questions to Ask

Specialist Referral

Disease #63: Thiamine Deficiency

Wernicke’s Encephalopathy

Korsakoff’s Syndrome

Wernicke-Korsakoff’s Syndrome

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Are Wernicke’s Encephalopathy and Korsakoff’s Syndrome?

Questions to Ask

Specialist Referral

Disease #64: Tourette Syndrome

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

Questions to Ask

Specialist Referral

Disease #65: Transient Global Amnesia

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Transient Global Amnesia?

Questions to Ask

Specialist Referral

Disease #66: Traumatic Brain Injury: Long-Term Consequences

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

Questions to Ask

Specialist Referral

Disease #67: Uremia (Chronic Kidney Disease)

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Uremia?

Questions to Ask

Specialist Referral

Disease #68: Vascular Dementia

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Vascular Dementia?

Questions to Ask

Specialist Referral

Disease #69: Vitamin B12 Deficiency (Including Pernicious Anemia)

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Vitamin B12 Deficiency?

Questions to Ask

Specialist Referral

Disease #70: Whipple Disease

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Whipple Disease?

Questions to Ask

Specialist Referral

Disease #71: Wilson’s Disease

Possible Presenting Mental Signs and Symptoms

Possible Physical Signs and Symptoms

Clinical Presentation

Clinical Course and Prognosis

Prevalence and Population at Risk

What Is Wilson’s Disease?

Questions to Ask

Specialist Referral

Bibliography

Author Index

Subject Index

End User License Agreement

Masquerading Symptoms

Uncovering Physical Illnesses That Present as Psychological Problems

Barbara Schildkrout

Cover image: © Beau Lark, Fancy/Jupiter Images

Cover design: Andrew Liefer

Copyright © 2014 by John Wiley & Sons, Inc. All rights reserved

Published by John Wiley & Sons, Inc., Hoboken, New Jersey

Published simultaneously in Canada

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400, fax (978) 646-8600, or on the web at www.copyright.com. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) 748-6011, fax (201) 748-6008, or online at www.wiley.com/go/permissions.

Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, they make no representations or warranties with the respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation. You should consult with a professional where appropriate. Neither the publisher nor the author shall be liable for damages arising herefrom.

For general information about our other products and services, please contact our Customer Care Department within the United States at (800) 762-2974, outside the United States at (317) 572-3993, or fax (317) 572-4002.

Wiley publishes in a variety of print and electronic formats and by print-on-demand. Some material included with standard print versions of this book may not be included in e-books or in print-on-demand. If this book refers to media such as a CD or DVD that is not included in the version you purchased, you may download this material at http://booksupport.wiley.com. For more information about Wiley products, visit www.wiley.com.

Library of Congress Cataloging-in-Publication Data:

Schildkrout, Barbara.

Masquerading symptoms: uncovering physical illnesses that present as psychological problems/Barbara Schildkrout.

pages cm

Includes bibliographical references and index.

ISBN 978-0-470-89065-3 (pbk.)

ISBN 978-1-118-23487-7

ISBN 978-1-118-22101-3

1. Medicine, Psychosomatic. 2. Psychological manifestations of general diseases. 3. Sick—Psychology. 4. Consultation-liaison psychiatry. I. Title.

RC49.S3354 2013

616.08—dc23

2013017805

Introduction

Non-specific behavioral and mood alterations often represent the very first and, occasionally for prolonged periods of time, the one single and exclusive sign of an undetected physical illness. Flagrantly and convincingly psychological in nature on presentation, such masked physical conditions frequently mislead the examiner and obliterate any further medical consideration, resulting in misdiagnosis and thus, inevitably, in treatment gone astray.

— E. K. Koranyi. (1979). Morbidity and rate of undiagnosed physical illnesses in a psychiatric clinic population. Archives of General Psychiatry, 36(4), 414.

Many medical conditions can produce mental symptoms as their dominant clinical feature. This creates a diagnostic problem. How is one to know whether an underlying medical disease might be the cause of a patient’s presenting psychological symptoms? This question is a serious one for all mental healthcare practitioners, indeed for all clinicians. In addition, patients and concerned family members often wonder whether an undiagnosed medical disease might be the basis of what appears to be a new, worsening, or unresponsive psychiatric disorder. In this book, I describe more than 70 specific medical diseases that may present with signs and symptoms that mimic psychological states or psychiatric disorders. Individuals who are suffering with one of these medical conditions might experience panic attacks or anxiety states, hallucinations, irritability, psychotic thinking, apathy, feelings of depression—the kinds of symptoms that lead patients to the offices of therapists, psychologists, psychiatrists, social workers, and counselors. Yet in some instances, and not infrequently, these disturbing states of mind are actually markers of serious, often treatable, medical disorders.

All of the diseases I present in this book are capable of producing mental symptoms that can be both distressing to the patient and diagnostically confusing to their caregivers. My goal is to help you—clinicians—as well as patients and families to become more familiar with these medical conditions and how they may masquerade as mental disorders. Ultimately, my aim is to facilitate coming to an accurate diagnosis of any underlying medical disease as quickly as possible. A competently made, scientifically based diagnosis is the most crucial step toward obtaining the most effective treatment available for the disease.

I have written Masquerading Symptoms: Uncovering Physical Illnesses That Present as Psychological Problems after more than 25 years of clinical experience as a psychiatrist. I wish that this book had been available to me during my earlier years of practice, for it brings together into one volume information that therapists can use to formulate which medical diagnoses might be producing their patients’ mental symptoms. Rather than simply describing a set of medical conditions, it introduces the mental presentations of these diseases, explaining how patients with each medical condition might end up in a therapist’s office, a mental health clinic, or a psychiatric inpatient unit.

In addition, this book emphasizes data needed for making a diagnosis that can be learned during an interview while sitting across the office from a patient—information that comes from establishing a relationship with the patient, taking a history, performing a mental status exam, and making careful observations. The text uses no medical jargon, yet it provides interesting and scientifically sophisticated information. The disease descriptions are concise and organized so that pertinent information can be easily accessed.

Another important feature of this book is its overall structure. Part One allows readers to look up a patient’s main behavioral or mental status findings and learn which medical diseases might display these features. Readers then can turn to the pertinent medical disease descriptions in Part Two. Thus it is possible for a clinician to develop a differential diagnosis—a list of possible diagnoses and the clinical evidence for each. This is the first step in efficiently and effectively referring the patient to the appropriate medical practitioner for a targeted medical workup.

As therapists, we are in a unique position. We often have more time with a patient than other clinicians; we may know the patient very well and might even be familiar with the patient’s family members. Yet often as therapists we feel that we do not know enough about medical diseases that might be contributing to or generating the mental symptoms for which patients have sought our help. In clinical practice, complex and confusing situations often arise. Patients arrive at the clinic with atypical presentations. Or a patient in the hospital might not respond to the usual treatment in the expected time frame. Even when we feel that we are providing optimal care, some of our patients actually get worse. It is at times like these that we often ask ourselves whether there might be an underlying medical condition that we are missing. This book provides the information that is needed to approach that question.

Getting to an accurate diagnosis can be a very long journey for the patient and the family as well as for the clinician. Although information about the classical mental presentations of some common diseases such as hypothyroidism or sleep apnea might be widely known, the less common presentations of these diseases might elude detection. Information about rare medical conditions is generally wanting, and patients with these diseases may go for many years without a diagnosis. As I was researching this book, I often came across statements in recently published journals that documented the time delays in making a correct diagnosis. For example, for acromegaly, in which alterations in body and mental symptoms develop gradually over years, a patient might suffer without a correct diagnosis for up to 10 years. Although acromegaly is a rare disease, narcolepsy is not. Yet the average time from symptom onset to the correct diagnosis for a patient with narcolepsy also can be more than a decade.

Clinicians may miss a diagnosis because they do not know enough about a particular disease and its manifestations. At other times, therapists simply have not had that particular diagnosis in mind. All too often the possibility that any medical disease might be contributory has not been considered seriously enough. In addition, a number of diseases actually are known for their propensity to elude detection. They have gained nicknames, such as the great imitator, great pretender, or medical masquerader, because of their ability to present in atypical forms, to come on gradually and escape notice, or to look like something other than what they are.

Making a diagnosis is like solving a mystery. How can all of the features of the patient’s presentation be explained? A clinical picture emerges from the complex interaction of multiple factors, including the possible contribution of multiple diagnoses and countless psycho-social forces. Figuring out how to understand the evolution of a patient’s clinical presentation involves extraordinarily difficult problem solving. This book does not underestimate how difficult a process that is.

All clinicians begin by noting the presenting features of an illness. We listen as our patients relate the nuances of how they feel; we observe the patient carefully, and we begin to hypothesize about what might be the matter. As mental health professionals we will take a thorough history, perform a complete mental status exam, obtain and review medical records from the past, and talk with the patient’s family and friends when appropriate. By far, most diagnoses are made on the basis of information gathered in this careful, thorough, and thoughtful manner.

Utilizing this book, it is possible for a therapist to take the information obtained during these clinical interviews and look up the salient presenting mental features in Part One. Then he or she can follow the trail of signs and symptoms to specific medical disease descriptions in Part Two. In short, this book provides clinicians with a vast fund of information about pertinent medical conditions as well as a way to access that information.

My hope is that readers will benefit from this book as a tool for their own learning while they also utilize it, day to day, as a reference for helping with the process of making a clinical diagnosis.

Masquerading Symptoms extends the theme of my earlier work, Unmasking Psychological Symptoms: How Therapists Can Learn to Recognize the Psychological Presentation of Medical Disorders. That first book provided a general introduction to the topic as well as a detailed discussion of how medical diseases escape our notice, what the important clinical clues to medical diseases are, and how to spot them in practice.

This current book gives readers in-depth descriptions of 71 medical diseases that can masquerade as mental disorders. Some of these diseases are common and familiar, such as disorders of the thyroid, sleep apnea, Alzheimer’s disease, and Parkinson’s disease.

Other diseases that are included in this book are common and unfamiliar, such as dementia with Lewy bodies, the second most common cause of dementia after Alzheimer’s disease. Dementia with Lewy bodies was recognized as a separate entity only in 1995, yet it affects millions of individuals. It is a dementia that does not present with memory loss, but often patients have well-formed visual hallucinations as an early symptom.

This book also introduces diseases that are uncommon and important—limbic encephalitis, night-eating syndrome, Hashimoto’s encephalopathy, and chronic low-dose carbon monoxide poisoning. Identifying even a single patient with one of these conditions offers the possibility of effective treatment and, at times, life-saving intervention.

I have chosen to focus this book on those diseases that are not usually considered to be within the purview of mental health clinicians. The boundaries of medical and psychological are changing. I hope that readers will understand that the medical diseases included in this book as well as the psychiatric disorders that are not included are all complex, biologically based diseases. Conditions such as schizophrenia, obsessive-compulsive disorder, depression, autism, and so on are as medical as migraine, restless legs syndrome, or frontotemporal dementia. As yet, we do not fully understand the multi-faceted, fundamental underlying mechanisms that produce any of these diseases.

Naturally, in the writing—and the reading—of this book, questions arise about the whether there is a difference between a medical disorder, a psychiatric disorder, and psychological disorder. What about a disorder as opposed to a disease or condition? And what actually is a diagnosis? Perhaps the biggest conundrum relates to the terms organic versus functional and physical versus psychological.

In this book, I have chosen to use the words disease, disorder, and condition interchangeably.

The term diagnosis is imperfect. Indeed there are some situations in which definitive, objective findings are used to define a diagnostic entity—laboratory tests for syphilis and computed tomography (CT scan) evidence for chronic subdural hematomas. For other conditions, there are consensus criteria that have been accepted by experts in the field—as with neuro-Behçet’s or multiple sclerosis. A diagnosis has predictive power, but this power does have limits. Two individuals with the same diagnosis might not have the same symptom presentation or clinical course—even if these patients have the same disease, even if that disease is genetic and the individuals have inherited the same defective gene.

I use the term psychological to refer to experiential states that are subjective.

I use the term psychiatric to refer to those diagnoses that have been given DSM status. I understand that these diagnostic categories shift; they are not based on etiology but rather on consensus about clusters of behavioral characteristics.

I use the term medical or physical when describing diseases that are widely accepted as specific entities and that are within the scope of practice of medical specialists.

Although language of this sort—physical, psychological—is in common usage, these words and phrases reflect a discredited notion that mind and brain are separate. I have tried to avoid this dualistic version of reality, but, unfortunately, we are saddled with a vocabulary that has old roots. Physicists introduced the term spacetime when their theories began to reveal that space and time, which had appeared to be fundamental, disparate concepts, actually were not separate. Perhaps a term such as mindbrain would better capture the complex realities: all mental phenomena have brain correlates; the brain is molded by experience—by every experience, at every moment; an individual’s way of perceiving and conceptualizing external phenomena is affected by biological determinants; genetic factors are altered by experience. To quote Michael Tomasello, There is thus no question of opposing nature versus nurture; nurture is just one of the many forms that nature may take.1

How This Book Is Structured

This book has two main parts. Part One is where you can look up a signs, symptoms, and behavioral features in order to figure out which Part Two diseases your patient might have. Part Two is where you will find disease descriptions.

The chapters in Part Two have a dual purpose. Each chapter first contains a discussion of the arena of signs, symptoms, or behavioral features that constitutes the chapter topic; the focus is on the diagnostic relevance of notable findings. Each chapter then provides an index to some of the diseases in Part Two that might display these findings. Part One contains the following chapters:

There are separate chapters for each of the categories of an expanded mental status examination. These chapters include: State of Consciousness; Attention and Concentration; Mood, Affect, and Emotion; Thought Form; Thought Content and the Experience of Reality; Delusional Thought Content; Hallucinations; Change in Personality or Behavior; Judgment; Insight; Orientation; Memory; Speech and Language; Other Cognitive Functions, including Constructional Ability (Drawing, Copying, and Visuospatial Tasks), Fund of Knowledge, Calculation, Abstract Thinking, and Executive Functions.

In addition, key chapters on Delirium and Dementia are included because each of these is comprised of characteristic constellations of mental features that signal the presence of a physical condition.

There is an important chapter on General Physical Appearance, reviewing the physical features a therapist might observe.

There is a separate section on Motor Behavior that discusses readily apparent tics and tremors, gait disturbances, catatonia, hyperactivity, and so on.

Part One also contains chapters on the Vegetative Symptoms of Sleep; Energy Level; Eating Behavior and Weight; and Sexual Interest and Functioning.

And, finally, there is a section that lists the Notable Physical Symptoms of patients who have the diseases that are discussed in this book.

Part Two contains 71 medical disease descriptions, in alphabetical order and numbered, so that they can be referenced and accessed easily.

Each disease description begins with a brief introduction that explains what the disease is and how it might present; mental status features and behavioral changes are highlighted. The introductory remarks also summarize concepts that are fundamental to understanding the disease. After the disease is introduced, all further information is presented in a standard outline format that makes it easy to look up exactly what you want to know.

The outline consists of these sections:

Possible Presenting Mental Signs and Symptoms. This section includes clinical findings that are part of a mental status examination, including cognitive features. Symptoms are subjective experiences that the patient reports, such as feeling anxious or hearing voices. Symptoms are usually what motivate someone to seek help. Signs are observed phenomena such as agitation or an emotionless facial expression. The patient may be unaware of these.

Possible Physical Signs and Symptoms. This next section emphasizes the patient’s reported physical complaints. Important physical changes that might be observed in a therapist’s office from across the room also are described. This book does not include those signs that might be found on a physical examination. Signs and symptoms in this section and in the previous section are listed in order of frequency and clinical importance.

Clinical Presentation. Here you will find a narrative description of the ways this disease might present, emphasizing how the patient experiences the disease and what might bring the patient to the attention of the health care system. This section puts signs and symptoms into the context of time. It answers questions such as: How does the disease begin? Do symptoms come on suddenly? Gradually? Is this an episodic illness? Does the patient generally feel that he or she has always been this way? Is this the sort of disease in which the family is terribly concerned while the patient feels that nothing’s the matter?

Clinical Course and Prognosis. This section continues the narrative and describes how the disease unfolds over time and what the outcome is likely to be, with and without prompt, appropriate treatment.

Prevalence and Population at Risk. How common is this disease? Who is most like to have this disorder? Is this a disease of the elderly or the young? What is the gender distribution? These kinds of questions are addressed in this section. In addition, the risk factors for developing the disease are presented. These risks might be genetic factors, occupational exposure, a history of head trauma, and so on.

What Is . . . ? This section explains the physiologic mechanisms that underlie the disease. The goal is to give readers enough information to better conceptualize the particular disorder and to understand why it presents in the ways it does. Some readers may simply be curious about the biological processes involved. Because of the magnitude and complexity of the information that might be available in this arena, the explanations in this section stop far short of presenting all that is known.

Questions to Ask. This is a guide to some of the important questions one might consider asking the patient (or, in some cases, the family) when trying to figure out whether the individual has this particular disease.

Specialist Referral. This section specifies which medical specialists would be most familiar with the particular diseases being discussed. In most clinical situations it is sensible to have the patient first consult with his or her primary care physician. It is generally helpful for the therapist to obtain permission to speak with this physician and to develop a cooperative working relationship. Primary care doctors are the ones who will likely be overseeing and coordinating any complex medical care that the patient might require. When there is concern that the patient might have a complex or a rare disease, it is highly recommended that a specialist be consulted. This section states which medical specialists have the expertise to diagnose and treat the disease in question.

Realistically, the logistics of finding a specialist may be extremely challenging, depending upon where the patient lives and what resources are available. In areas where there are academic centers it may be possible to find physicians who are not only specialists, but also super-specialists. Thus, for someone who might have a seizure disorder, there are not only neurologists in practice but also seizure specialists, epileptologists. In addition, behavioral neurologists, neuropsychiatrists, and neuropsychologists each have areas of special expertise to offer such a patient.

Cases. Most of the disease discussions are followed by excerpts of case reports from the published scientific literature. The significance of each case example is noted briefly. Every effort has been made to find cases that have a human, narrative element as a way to bring the manifestations of each particular disease to life. These cases also have been selected for their relevance to the topic of this book in that they illustrate the mental manifestations of the disease and how the disease might present as a confusing diagnostic problem. Any medical terminology that might be contained in the excerpts is explicated in brief bracketed notations.

At the end of the book, readers will find a list of references for each disease entity.

What This Book Does Not Include

This book has a clearly defined focus: medical conditions that can masquerade as mental disorders and that present in adulthood. The book was designed to be used primarily by trained professionals to aid in diagnosing patients and to facilitate their own learning. In addition, patients and families might benefit by using the information in this book to inform their efforts at obtaining effective professional help.

In focusing this book on one clinical arena, other areas of knowledge could not be included.

This book does not include every possible medical disease that a patient might have. This book is not a diagnostic manual. Patients might have diseases that are not included in this text. Even for those diseases that are included, nothing can substitute for clinical experience or for a medical education.

This book also does not include diseases that present in childhood, even if the disease persists into adulthood.

Although this book does include some rare diseases, it does not include every disease entity that could possibly mimic a psychological disruption or psychiatric disorder.

The book does not include diseases that are obviously medical or surgical disorders. Comatose patients, acute head trauma, obvious signs of infection such as a fever and acute onset, clear impairment in neurologic functioning such as double vision or sudden weakness of a limb—these presentations signal to all involved that the patient needs the care of a medical physician, and urgently.

In addition, many diseases do not, in and of themselves, produce manifestations in the mental sphere; yet in an individual who already has a psychiatric disorder or some other vulnerability (such as a dementia), these diseases might lead to changes in behavior, cognition, mood, or other aspects of mental status. A classic example of this is a urinary tract infection in someone with a mild dementia; together these produce an altered mental state, namely a delirium. There might be no overt indication of the presence of an underlying urinary tract infection other than this change in mental state. Moreover, that alteration in mental status might linger for weeks after effective antibiotic treatment. Medical diseases like the urinary tract infection in this example are not included in this book.

This book does not include states of intoxication or withdrawal from alcohol or from drugs of abuse. These conditions are extremely important mimics of psychiatric disorders and are capable of producing a vast variety of mental status changes. They are not included because of space limitations. In addition, although an accurate history may be difficult to obtain in patients with intoxication or withdrawal syndromes, these diagnoses often rest mainly on a reported history of use and then laboratory toxicology results.

Clinicians need to always have states of intoxication and withdrawal in mind as diagnostic possibilities. Patients are extremely vulnerable in these altered states. Toxic levels of alcohol and substances of abuse can be lethal; patients may be psychotic and/or combative; they may exercise poor judgment. Withdrawal from alcohol may take the form of a paranoid hallucinatory psychosis or delirium tremens, a condition that is fatal in a substantial percentage of individuals. The patient history—possibly obtained from family or friends—is a crucial factor in making the diagnosis, as always, along with having the possibility in mind.

This book also does not include the effects of prescription medications and other substances, such as supplements or vitamins, herbal or traditional remedies, over-the-counter medications, or pharmaceuticals obtained through the Internet or from abroad. Using a reliable source, it is useful to look up reported side effects of the medications a patient is taking. Also, it is possible to contact the pharmaceutical manufacturer or the Food and Drug Administration to find out whether a patient’s symptoms have appeared in the adverse drug reports they compile.

Perhaps the most important mimics of neuropsychological conditions are medication reactions; these are common and relatively easy to diagnose and treat. Corticosteroid medications, multiple medications with atropine-like effects, or those that increase serotonin levels deserve special note as do drug interactions in which the metabolism and blood level of one drug is influenced by the addition of another.

Again, the patient history is the foundation for identifying these possibilities. Obtain a list of every medication and substance that a patient is using, along with information about when the patient started taking each, whether and when there was a dosage change, when the patient stopped taking any of the medications, and how compliant the individual is with the recommended dosing. Correlating these factors with the onset of the patient’s neuropsychological presentation has solved many a mystery diagnosis.

I have opted to omit specific neuro-anatomical information in describing the diseases. Although this information is scientifically and clinically extremely important, I concluded that it was too technical for this book and for the purposes of making a first-pass clinical diagnosis.

The number of case reports that I have included was limited by several factors. Often I simply did not find cases in the literature that met my criteria for inclusion: The diagnosis was certain, the patient presented with mental status or behavioral abnormalities, and there was enough narrative content to make the case come alive. Many excellent cases could not be included because the permission costs for excerpts were prohibitive.

This book does not include recommendations for diagnostic tests. The focus is on helping clinicians to decide when to refer the patient for a medical workup. The book does include recommendations as to which medical specialists might be consulted in addition to having the patient see a primary care physician. It assumes that a primary care physician will coordinate care.

Patients with most of the diseases that are highlighted in this book could benefit significantly from mental health services. Their family members are often in need of such services as well. I have not included recommendations for these mental health services for a number of reasons. In many cases, patients are already seeing a therapist because they have been thinking they have a mental disorder. In other cases, patients are already being cared for in a mental health clinic or a psychiatric inpatient service. In addition, while writing the book, initially I found that I was including recommendations for counseling, social service support, psychotherapy, and/or behavioral interventions of various kinds at the end of virtually every disease write-up (in the Specialist Referral section). I felt that this general recommendation was too repetitious and that more detailed, specific advice would require its own volume.

Acknowledgments

I was inspired by the work of Bernard I. Comroe, Richard C. W. Hall, Lorrin M. Koran, Erwin K. Koranyi, Barbara L. Yates, and many others who studied psychiatric patients and documented that undiagnosed medical disease was frequently the sole cause of a patient’s mental presentation or a significant contributing factor that needed to be addressed as part of effective treatment. I also want to acknowledge the extraordinary work of William Alwyn Lishman in compiling his classic medical reference, Organic Psychiatry: the Psychological Consequences of Cerebral Disorder. These individuals along with countless other clinicians and researchers were pioneers who first investigated and wrote about this important topic—medical diseases masquerading as mental conditions.

I want to express profound gratitude to family, friends, and colleagues who gave me encouragement and support during the long road to producing this book. Especially, I wish to thank my dear friends Nancy and Standish Hartman, Jeane Ungerleider and William Stone, Ellen and George Fishman, Fred and Lois Kanter, and Meg Campbell. They have provided wise counsel, perspective, and humor—over many years, through good and bad times.

I am deeply grateful to Carol Nadelson for her inspiring ideas, sound advice, and generosity of spirit.

Thank you to Karen Greenberg for being a teaching and learning partner. I treasure the trust and friendship that have grown from our having pondered and wrestled with scores of clinical and teaching dilemmas.

I want to express my appreciation to Albert Galaburda, who provided me with an arena in which to learn and engaged in answering my endless questions. Al has enriched my life with his friendship and support and that of Susana Camposano, Bonnie Glickman, and Sam Frank.

I have prized the opportunity to share ideas with outstanding clinicians; I have grown from these interactions and so have our friendships. Thank you to Margaret O’Connor, Lissa Kapust, Mark Thall, Sara Hoffschmidt, Daniel Press, Sheldon Benjamin, Margo Lauterbach, Miriam Freidin, Eileen Kahan, and Beverly St. Claire.

Thank you to Daniel Fishman, who was masterful at the detailed task of arranging permission to use excerpts of case reports for this book. He also compiled the data on incidence and prevalence for each disease.

I also want to thank Kara Borbely (editorial program coordinator) for her expertise and generous help with endless details and questions and Kim Nir (production editor), who is remarkable for her professionalism and collaborative spirit.

Truly, words cannot express how grateful I am to my editor, Patricia Rossi, who helped to shape this book and brought it to fruition. It was through her efforts that this text is now available to help clinicians, families, and patients. I have benefited from Patricia’s guidance, encouragement, and patience. Her extraordinary curiosity, empathy, respect, and trust have been inspiring.

My mother has been cheering me on from the very beginning. Even now, in her 90s, she continues to follow the progress of my work. I want to express my profound gratitude for her abiding belief in the value of education and learning.

To Aaron Schildkrout, Emily Schildkrout Fine, Aaron Fine, and Emet Isaiah Fine (now one and a half years old): You are the sustaining joy of my life. I cherish the depth and honesty of our relationships. I take pleasure in seeing each of you devoted to missions of your own choosing, as I have been devoted to this book project. Thank you for your patience and support over the many years during which working on my book has been a presence in all of our lives.

Disclaimers

This book cannot substitute for a formal consultation with a competent physician. The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians or other clinicians for any particular patient. The publisher and author make no representations or warrantees with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warrantees, including without limitation any implied warrantees of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warning and precautions. Readers should consult with a specialist where appropriate.

The fact that an organization or Web site is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Web site may provide or recommendations it may make. Furthermore, readers should be aware that Internet Web sites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statement for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.

1Michael Tomasello. (1999). The cultural origins of human cognition Cambridge, MA: Harvard University Press, p. 212.

List of Diseases by Organ System or Disease Process

Developmental and Genetic Disorders