[NYAPRS Enews] WSJ: Confusing Medical Ailments With Mental Illness

[Harvey Rosenthal]

Confusing Medical Ailments With Mental Illness

by Melinda Beck  Wall Street Journal  August 9, 2011

 

An elderly woman's sudden depression turns out to be a side effect of
her high blood-pressure medication.

A new mother's exhaustion and disinterest in her baby seem like
postpartum depression-but actually signal a postpartum thyroid imbalance
that medication can correct.

A middle-aged manager has angry outbursts at work and frequently feels
"ready to explode." A brain scan reveals temporal-lobe seizures, a type
of epilepsy that can be treated with surgery or medication.

More than 100 medical disorders can masquerade as psychological
conditions, according to Harvard psychiatrist Barbara Schildkrout, who
cited these examples among others in "Unmasking Psychological Symptoms,"
a book aimed at helping therapists broaden their diagnostic skills.

Studies have suggested that medical conditions may cause mental-health
issues in as many as 25% of psychiatric patients and contribute to them
in more than 75%.

Untangling cause and effect can challenge even seasoned clinicians, and
the potential for missed diagnoses is growing these days, said Dr.
Schildkrout, who has more than 25 years of clinical practice in the
Boston area. Most mental-health counselors rely on primary-care doctors
to spot medical issues, but those physicians are increasingly
time-pressed and may not know their patients well. Neither do the
psychiatrists who mainly write prescriptions and see patients only
briefly, she said in an interview.

Common culprits include under- or over-active thyroid glands, which can
cause depression and anxiety, respectively. Deficiencies of vitamins D,
B-12 and folate, as well as hormonal changes and sleep disorders have
also been linked to depression.

Diabetes, lupus and Lyme disease can have a variety of psychiatric
symptoms, as can mercury and lead poisoning and sexually transmitted
diseases. Many medications also list mood changes among their side
effects, and substance abuse is notorious for causing psychiatric
problems.

Some underlying conditions are readily treatable. Others, such as
Alzheimer's and Parkinson's disease and some brain tumors, are not. But
a correct diagnosis can save months or years of frustration and
ineffective treatment.

In some cases, a psychological problem is just the first sign of a
serious medical issue. "Depression predicts heart disease and heart
disease predicts depression," said Gary Kennedy, director of the
geriatric psychiatry at Montefiore Medical Center in Bronx, N.Y.

About one-third of people who have their first episode of depression
after age 55 have changes in brain circuits that are associated with
hypertension, diabetes and heart attacks. Such patients are usually
apathetic, have difficulty with executive planning and don't respond
well to antidepressants. Making sure their blood pressure and
blood-sugar levels are on target is crucial, though medical and
psychotherapy may be needed as well, Dr. Kennedy said.

Recognizing an underlying medical condition can be particularly
difficult when there is also a psychological explanation for a patient's
dark moods. For example, victims of domestic violence are often anxious,
depressed and withdrawn-but mild brain injury could be causing such
symptoms, too.

Similarly, a former college athlete who becomes angry and irritable in
his 40s could be suffering a midlife crisis-or delayed reaction to head
injuries sustained decades earlier. "We now know that multiple
concussions can have a sleeper effect for years. Then one day, out of
the blue, you start acting explosive and depressed," due to a brain
swelling known as chronic trauma encephalopathy, said Jerrold Pollak, a
neuropsychologist at Seacoast Mental Health Center in Portsmouth, N.H.,
and lead author of an article on distinguishing mental from medical
disorders in the Journal of Clinical Psychology Practice this spring.

If the head-injury diagnosis is missed, Dr. Pollak added, the patient
could be in psychotherapy for months, "thinking that he has trouble with
his father or feels like a failure for not becoming a pro athlete."

Giving every patient who seeks psychological help a brain scan first
would be prohibitively expensive and likely yield many confusing
results. But experts say mental-health counselors should ask patients
about their medical histories as well as emotional issues, and make sure
they've had a recent physical exam.

Tell-tale signs of underlying medical problems include significant
changes in energy, weight, appetite or sleep, which could be due to an
endocrine disorder. Sudden changes in mood or personality, visual
hallucinations and alternations in smell, taste or tactile senses could
signal a brain tumor or other abnormality.

Sometimes a single physical sign can broaden a clinician's diagnostic
thinking. Manhattan psychiatrist Drew Ramsey recalled that early in his
career, he examined a patient with daily panic attacks and noticed a
swelling on her shins, a classic sign of Graves' disease, a form of
overactive thyroid that can cause severe anxiety.

Like other psychiatrists, Dr. Ramsey said he always takes a medical
history and orders blood tests for patients. He found that one was
anemic and improved markedly when meat was added to her diet. Another
who was depressed and drinking heavily was low on vitamins D and B-12.

Similarly, Dr. Schildkrout once treated a 50-year-old woman for mood
swings and noticed a slight slurring to her speech. While it could have
been dismissed as ill-fitting dentures, it turned out to be the first
sign of amyotrophic lateral sclerosis, which also causes severe fatigue
and odd jags of laughing and crying in its early stages.

Some patients may benefit from both psychological counseling and medical
help. Therapists need not turn patients away while medical issues are
being explored, experts say. "Clinicians can say, 'While we work on
these issues, let's also discuss any possible medical conditions that
could be contributing, so we can at least rule them out,"' Dr. Pollak
said.

Finally clarifying a diagnosis can be a relief to clinicians and
patients-particularly when therapy hasn't been working or patients have
spent years blaming themselves. "When you find the right diagnosis, not
only is there appropriate treatment, but it can make a dramatic
improvement in terms of healing their self esteem," Dr. Schildkrout
said.

 

Different Diagnoses

More than 100 medical disorders can masquerade as psychological
conditions or contribute to them, complicating treatment decisions.

WHAT 
SEEMS LIKE ...

MAY ACTUALLY BE ...

Depression

Underactive thyroid; low vitamin D or B-12 or folate; diabetes; hormonal
changes; heart disease; Lyme disease; lupus; head trauma, sleep
disorders; some cancers and cancer drugs

Anxiety

Overactive thyroid; respiratory problems; very low blood pressure;
concussion; anaphylactic shock

Irritability

Brain injury; temporal lobe epilepsy; Alzheimer's disease and early
stage dementia; parasitic infection; hormonal changes

Hallucinations

Epilepsy; brain tumor; fever; narcolepsy; substance abuse

Cognitive changes

Brain injury or infection; Alzheimer's; Parkinson's; liver failure;
mercury or lead poisoning

Psychosis

Venereal disease; brain tumors and cysts; stroke; epilepsy; steroids;
substance abuse

Source: WSJ reporting

 

Warning Signs

When to suspect a mental problem may be medical:

* Sudden change in mood or personality

* History of head trauma

* Depression that occurs for the first time after age 55

* Recent travel or exposure to infections

* Any rash, swelling, drooping eyelid; facial tic

* Standard medication or therapy isn't effective

 

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