Organicity in psychiatry

Organicity is about considering the critical role of physical or physiological factors in the manifestation of psychiatric symptoms and signs, particularly in cases where:

  1. There is significant deviation from the expected presentation of diagnosed functional psychiatric disorders (including demographic factors and history of presentaton), and/or
  2. There is evidence of treatment resistance or poor response to conventional treatments typically effective for functional conditions, and/or
  3. There is rapid re-emergence following an initial positive response to treatment, suggesting an underlying and unresolved aetiological factor, and/or
  4. There are manifestations of atypical or unusual patterns not readily explained by known psychiatric diagnoses.

Whilst recognising that all psychiatrists have a duty to investigate whether physical illness may account for psychiatric symptoms, consideration of organicity takes a more focused angle based on the definition above. It means that there is an emergent need to search harder for uncommon or rare contributing factors.

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Limitations

The objective of this article is not to provide answers or solutions. It is about providing ready access to possible conditions that may be of organic importance in specific cases, when there is a real clinical need to look deeper.

This resource will not itemise what sort of tests or investigations psychiatrists should do. That is left to their own competence, to be decided in consultation with other specialists.

The information and ideas presented are mainly for adult patients between 18 and 65. There is limited application to young persons and those in later life (>65).

Case vignettes

ScenarioConsiderationsActionsActions & Outcomes
Mrs. K, a 65-year-old woman with a 40-pack-year smoking history and a past diagnosis of breast cancer successfully treated five years prior, presented with a sudden onset of auditory hallucinations and persecutory delusions. there was no previous psychiatric history.

She reported hearing voices commenting on her actions and believed that her conversations were being monitored via satellites.

Her history of cancer was not identified on first contact with services.
Initial treatment with antipsychotic medication provided minimal relief. Her paranoia intensified, leading to social withdrawal and increasing distress. Increased does of antipsychotics did not help.
On review by different consultant psychiatrist. The history of breast cancer was discovered.

The atypical presentation, particularly the sudden onset and lack of prior psychiatric history, along with her significant smoking history and past cancer treatment, prompted a deeper investigation into potential organic causes.

While a sudden recurrence with brain metastases after 5 years of remission is less common, it is not implausible in Mrs. K’s case due to the following factors:
Smoking History: Her 40-pack-year smoking history significantly increases her risk of cancer recurrence and metastasis. Smoking is associated with more aggressive tumor behaviour and a higher likelihood of developing brain metastases in breast cancer patients.
Lack of Information on Original Tumor: We lack crucial details about her original breast cancer, such as its subtype, stage, and molecular characteristics. Some breast cancers, like triple-negative breast cancer (TNBC), have a higher propensity for late recurrences and brain metastases. Even if her initial treatment was successful, the specific biology of her tumor might predispose her to a late relapse.
Limitations of Surveillance: While Mrs. K was presumably under regular follow-up, current surveillance methods may not always detect small or asymptomatic brain metastases.
Atypical Presentation: The sudden onset of psychotic symptoms without a prior psychiatric history is a red flag. While psychiatric manifestations can occur in breast cancer patients, especially those with advanced disease, a sudden and dramatic change in mental status warrants further investigation to rule out organic causes, especially in the context of her risk factors.
A literature review was undertaken.

Evidence supporting the association between smoking and more aggressive tumor behaviour and a higher likelihood of developing brain metastases in breast cancer patients:
Nicotine’s Role in Metastasis:
A 2021 study published in Nature Communications found that nicotine exposure creates a favorable environment in the lungs for the growth of metastatic breast cancer cells.
Research from Wake Forest School of Medicine also indicates that nicotine can promote the spread of lung cancer cells to the brain, suggesting a similar mechanism could be at play in breast cancer metastasis.
Impact on Tumor Biology:
Several studies have shown that smoking can influence the tumor microenvironment, promoting inflammation, angiogenesis (new blood vessel formation), and immunosuppression, all of which can contribute to more aggressive tumor behaviour and metastasis.
Smoking has also been linked to alterations in gene expression and signaling pathways within breast cancer cells, potentially enhancing their metastatic potential.
Clinical Studies:
A meta-analysis published in the Journal of Clinical Oncology in 2017 found that smoking was associated with a significantly increased risk of breast cancer recurrence and mortality, particularly in patients with estrogen receptor-positive tumors.
Another study in the Journal of Thoracic Oncology in 2016 reported that smoking was an independent predictor of brain metastasis in patients with HER2-positive breast cancer.
Observational Data:
Multiple observational studies have consistently demonstrated a higher incidence of brain metastases in breast cancer patients who smoke compared to those who have never smoked.
The patient was offered a full range of basic blood tests and a range of more specific tests to screen for cancer.
MRI was offered.
The need for the tests were explained supportively in a consent dialogue.
The patient accepted all offers.

Naturally no one hopes to find a cancer. But if there is one that as emerged and spread, then something can be done.

The patient has a right to know.
ScenarioConsiderationsActionsOutcomes
Ms. P, a 35-year-old woman with no prior psychiatric history, presented with a six-month history of profound fatigue, apathy, and difficulty concentrating. She also reported experiencing frequent headaches and unexplained weight gain. She appeared to have a round face with, increased facial hair. She said that she always had a problem with facial hair.

Initially, her symptoms were attributed to major depressive disorder, and she was started on an antidepressant medication.

Despite several weeks of treatment, Ms. P reported no significant improvement in her mood or energy levels. In fact, her fatigue worsened, and she began to experience episodes of confusion and dizziness. Additionally, she noted a significant weight gain and a change in her posture, with a tendency to hunch forward.

The lack of response to antidepressant treatment, coupled with the atypical presentation of her depressive symptoms and the presence of additional physical complaints, prompted a reconsideration of the initial diagnosis.
The possibility of an underlying organic cause was explored by a different consultant psychiatrist, further investigations were recommended: blood tests to assess thyroid function, a full hormonal profile, vitamin levels, and inflammatory markers, as well as brain imaging to rule out structural abnormalities.The blood tests revealed significantly elevated levels of cortisol, indicating Cushing’s syndrome, a rare endocrine disorder caused by excess cortisol production. Brain imaging showed no significant abnormalities.

Ms. P was referred to an endocrinologist for further evaluation and management of Cushing’s syndrome. Treatment focused on identifying and addressing the underlying cause of excess cortisol, which could involve surgery, radiation therapy, or medication.

With appropriate treatment, her psychiatric symptoms improved alongside the resolution of her underlying endocrine disorder.
ScenarioConsiderationsResponseOutcomes
Mr. H, a 45-year-old man with no prior psychiatric history, presented with escalating anxiety and panic attacks over the past three months. He described a constant sense of dread, accompanied by palpitations, shortness of breath, and trembling. He also reported difficulty sleeping and a significant decrease in appetite.

An initial diagnosis of panic disorder was made, and Mr. H was started on a combination of an antidepressant and a benzodiazepine for immediate relief of his anxiety symptoms.
While the benzodiazepine provided some temporary relief,

Mr. H’s anxiety persisted despite adherence to his antidepressant medication. He continued to experience frequent panic attacks and reported feeling increasingly agitated and restless.
The lack of sustained response to appropriate medication, coupled with the escalating nature of his anxiety, prompted a reassessment of his diagnosis and a search for potential contributing factors.Further investigations were initiated, including blood tests to assess thyroid function, complete blood count, and electrolyte levels, as well as an electrocardiogram (ECG) to evaluate his cardiac function.The blood tests revealed markedly elevated levels of thyroid hormones, confirming a diagnosis of hyperthyroidism. The ECG showed sinus tachycardia, consistent with the hyperthyroid state.

Mr. H was referred to an endocrinologist for further management of his hyperthyroidism.

Treatment options were discussed, including antithyroid medication, radioactive iodine therapy, or surgery.

With appropriate treatment, his anxiety symptoms were expected to subside as his thyroid hormone levels normalised.







Discipline in understanding organicity

Understanding when to think deeper about organicity requires discipline.

The Organicity Checker is a free resource created by the author. It is a clinical activity. Not a diagnostic instrument. Discipline means a structured approach in thinking. It would be poor use of resources to order ‘every test in the book’.

This table herein does not mean that every patient needs a brain scan. The following are what should be running through the mind of a psychiatrist, in assessing any case.

Table 1 – Broad range of physical illnesses to be considered
Physical IllnessCommonest Age Group (Years)Brief Description of Psychiatric Symptoms
Urinary Tract Infection (UTI)>60Confusion, agitation, poor sleep
HypothyroidismAny, but more common in women >50Depression, fatigue, poor concentration
Hyperthyroidism20-40Anxiety, irritability, restlessness, hypomanic or manic signs or behaviours
Vitamin B12 & folate Deficiency>60 or those with malabsorptionDepression, psychosis, memory problems
AnaemiaAny, varies by causeFatigue, apathy, difficulty concentrating
DehydrationAny, risk increased in elderly & infantsConfusion, irritability
HypoglycaemiaDiabetics, any ageAnxiety, confusion, irritability
Sleep ApnoeaAny, more common in men & overweight individualsFatigue, irritability, difficulty concentrating
Brain TumourAny, varies by typePersonality changes, cognitive impairment, seizures
Systemic Lupus Erythematosus (SLE)15-45, more common in womenDepression, anxiety, psychosis
Lyme DiseaseAny, risk varies by locationFatigue, cognitive impairment, mood swings
HIV/AIDSAny, risk varies by exposureDepression, anxiety, cognitive impairment
SyphilisAny, risk varies by sexual activityPersonality changes, psychosis, dementia
Wilson’s DiseaseAdolescents & young adultsPsychiatric symptoms vary, can mimic many conditions

The table herein applies when there is a need to look deeper.

Table 2 – Uncommon syndromes across age groups.
Uncommon SyndromeCommonest Age Group (Years)Brief Description of Psychiatric Symptoms
Cushing’s Syndrome20-50, more common in womenDepression, anxiety, irritability, psychosis
PorphyriaAny, varies by typeAnxiety, depression, psychosis, confusion
PellagraAny, risk increased in those with poor nutrition or malabsorptionDepression, anxiety, psychosis, dementia
Wernicke-Korsakoff SyndromeAdults with chronic alcohol abuseConfusion, amnesia, confabulation, apathy
Addison’s DiseaseAny, but typically 30-50Fatigue, depression, irritability
Paraneoplastic SyndromesVaries, depends on underlying cancerAnxiety, depression, psychosis, cognitive impairment
Autoimmune EncephalitisAny, but more common in young adults & childrenPsychiatric symptoms vary widely, can include psychosis, seizures, personality changes
Normal Pressure Hydrocephalus (NPH)>60Cognitive impairment, apathy, gait disturbance
Hepatic EncephalopathyAdults with liver diseaseConfusion, apathy, sleep disturbances
Anti-NMDA Receptor EncephalitisYoung adults & children, more common in womenPsychiatric symptoms vary widely, can include psychosis, seizures, personality changes

A look into the rarest syndromes.

Table 3 – Rare syndromes across age groups
Rare SyndromeCommonest Age Group (Years)Brief Description of Psychiatric Symptoms
Fahr’s DiseaseAdults, typically >40Cognitive impairment, psychosis, movement disorders
Huntington’s Disease30-50Personality changes, depression, psychosis, chorea
Niemann-Pick Disease Type CInfancy to adulthood, varies by typeCognitive impairment, psychosis, seizures
Metachromatic LeukodystrophyInfancy to adulthood, varies by typeCognitive impairment, psychosis, personality changes
Wilson’s DiseaseAdolescents & young adultsPsychiatric symptoms vary, can mimic many conditions
Lesch-Nyhan SyndromeInfancySelf-injurious behaviour, cognitive impairment
Kleine-Levin Syndrome (KLS)Adolescents & young adultsHypersomnia, hyperphagia, cognitive impairment, behavioural changes
Morvan’s SyndromeAdultsInsomnia, hallucinations, autonomic dysfunction
Autoimmune Limbic EncephalitisAny, but more common in adultsPsychiatric symptoms vary widely, can include psychosis, seizures, personality changes
Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL)Adults, typically 30-50Cognitive impairment, mood swings, apathy
Lead and metals toxicityAny, but children and older-age adults are the focus of attention. See: https://mosaicdx.com/resource/the-role-of-heavy-metals-and-environmental-toxins-in-psychiatric-disorders/Exposure to lead or other heavy metals can cause a range of neuropsychiatric symptoms, including cognitive impairment, irritability, aggression, mood swings, and even psychosis. In cognitively impaired individuals, these effects can be particularly pronounced and challenging to manage. Early detection and treatment are essential to minimise long-term consequences.

In this part there is specific consideration about patients with cognitive impairments. Their symptoms and signs my present differently to other groups of patients.

Table 4 – specific considerations for the cognitively impaired (developmental or acquired.)
Physical Illness SyndromeBrief Description of Psychiatric Symptoms
DeliriumAcute confusional state with fluctuating consciousness, attention deficits, disorganised thinking, and altered perception. Can be triggered by various factors, including infections, medications, metabolic imbalances, and environmental changes.
Dementia-Related Behavioural & Psychological Symptoms (BPSD)Wide range of neuropsychiatric symptoms associated with dementia, including agitation, aggression, wandering, apathy, depression, anxiety, hallucinations, delusions, and sleep disturbances. Can significantly impact quality of life and caregiver burden. Requires a person-centred approach, addressing underlying causes and providing appropriate support and interventions.
Pain SyndromesChronic pain can lead to depression, anxiety, irritability, and sleep disturbances. In cognitively impaired individuals, pain may be expressed through non-verbal cues like agitation, restlessness, or withdrawal. Careful assessment and management of pain are essential to improve quality of life and address associated psychiatric symptoms.
Sensory ImpairmentsHearing or vision loss can contribute to social isolation, withdrawal, confusion, and anxiety. In cognitively impaired individuals, these impairments may exacerbate existing challenges and lead to increased frustration or agitation. Addressing sensory impairments through appropriate aids and support can improve communication, reduce anxiety, and enhance overall well-being.
Medication Side EffectsCertain medications, particularly those commonly used in older adults or individuals with cognitive impairment, can cause or worsen psychiatric symptoms. Examples include anticholinergics, benzodiazepines, antidepressants, and antipsychotics. Careful medication review and adjustment may be necessary to minimise adverse effects and improve mental health outcomes.
Urinary Tract Infections (UTIs)Although common in older adults, UTIs can present with atypical symptoms in cognitively impaired individuals, including confusion, agitation, and behavioural changes. Prompt recognition and treatment are crucial to prevent complications and improve mental status.
Infections (e.g., pneumonia, sepsis)Infections can cause delirium or worsen existing cognitive impairment, leading to confusion, agitation, and other psychiatric symptoms. Addressing the underlying infection is essential for improving mental status.
Metabolic Imbalances (e.g., electrolyte disturbances, hypoglycemia)Electrolyte disturbances and hypoglycemia can cause confusion, irritability, and other psychiatric symptoms, particularly in cognitively impaired individuals. Identifying and correcting these imbalances is crucial for improving mental health.
Sleep DisordersSleep disturbances, including insomnia, sleep apnea, and restless leg syndrome, are common in cognitively impaired individuals. These can exacerbate existing psychiatric symptoms and contribute to daytime fatigue, irritability, and difficulty concentrating. Addressing underlying sleep disorders can improve mental health and overall well-being.

Conclusion

This article aims to provide discipline and structure when thinking about cases where underlying organics factor may explain four main scenarios.

The Organicity Checker as a free resource was presented to assist discipline in thinking deeper about the four main scenarios.

Psychiatrists will hopefully benefit from this exploratory approach.