General Principles for Spotting Medical Mimics
Obviously, it is not possible to be cognizant of all medical mimics of mental disorders. What, then, can a therapist do? Most importantly, during your initial meeting, before attempting to begin the actual psychotherapy, allow time for structured questioning. This will allow you to apply the following principles to the evaluation process and have the significant added benefit of reassuring your patient. Here are several rules to keep in mind to help you spot most medical’ mimics:
- Never assume that an emotional symptom has a psychosocial cause until physical causes (or contributors) are fully investigated. The above two cases demonstrate this first rule of thumb. Your first presumption should be that symptoms are medically caused until proven otherwise. This is the opposite of how most professionals think, including those who have been medically trained. Adopting this rule as a working assumption will result in the uncovering of hidden physical factors before psychosocial treatment is initiated – when the disease process is less advanced – rather than after the psychosocial therapy has failed to produce improvement or, worse, the underlying disease process has become so advanced that it demands medical attention. There are well over 100 disorders that can mimic mental illness. As a therapist you may be the first one in the health care system to be alerted to the presence of a disorder. In order to be attuned to the first signs of illness, you must broaden your view of your role: You are no longer only interested in the psychosocial part of the person; you are treating the whole person, and that encompasses the entire biopsychosocial model.
- Always have your patients get a very complete physical examination if they haven’t had one since their symptoms began. The same applies in the case of marital therapy. It is reasonably common for one or both members of a couple to have some type of emotional disorder, such as a drug problem, attention deficit disorder, dysthymia, or an anxiety disorder. These disorders are destructive to self-esteem, affective stability, communication, and empathy. Each spouse must be fully evaluated to rule out medical mimics and then treated pharmacologically if appropriate.
- Look for a history that doesn’t fit. When a patient comes to you with a series of complaints, you must be a detective. As an example, I recall Mrs. Able, who was 48 when her husband of 23 years left her. She was quite functional and felt fine for the first 18 months of her separation. Gradually, however, she became fatigued and depressed. She began to complain of low back pain. Her physician told her it was stress related to the separation and referred her to a trusted psychotherapist for counseling. After six months of counseling, she fractured her thigh. X-rays revealed a suspicious area that turned out to be cancer, which was also present in her lower back and thus the cause of her pain. Mrs. Able died one month later. In this case, the therapist might have questioned the internist’s diagnosis, since the 18 months of good functioning after separation does not fit with the conclusion that she was psychologically stressed by her separation. That this history does not fit is common sense, requiring good listening skills and an openness to medical mimics. Her physician lacked the former, and her therapist the latter. As a therapist, you must develop trust in your own medical common sense.
- Check personal and family history thoroughly. Take a careful history. Look for depression, gambling, alcohol and drug use, suicide, obesity, panic, agoraphobia, institutionalization, etc., in three generations. If thorough assessment of an extended multigenerational family history fails to reveal biological relatives who have the same or related mental disorders, be suspicious of a mimic. It is rare for someone presenting with depression or anxiety to have a family history that is absent of any comorbid disorders. If the symptom pattern is not consistent with the family history, be suspicious. Mrs. Garth, a 52-year-old married female, was described by the referring psychiatrist as having loose associations and hallucinations. She was admitted to the hospital with a diagnosis of schizophrenia. A family history (obtained from her husband) revealed some obesity but no major mental disorder. Close examination of her speech pattern revealed difficulty naming objects and substitution of incorrect words, as opposed to classic loose associations. A neurologic work-up revealed a brain tumor, and she was transferred to neurology.
- Be suspicious if the onset of the disorder is late in life, and / or there are no stresses present. The age of Mrs. Garth illustrates this point well. Tohen, Shulman, and Satlin (1994) found that patients who had first-episode mania in the older age brackets were twice as likely as younger patients to have a neurological disorder. In addition to the case of Mrs. Garth, this reminds me of a 72-year-old woman who came to me with a psychotic depression. Her first episode began when she was 45. She had since had five episodes and was treated with psychotherapy and marital counseling, but never received medication. When I referred her for both a neurological and cardiac evaluation, she was found to have a blockage in her carotid artery (one of the main arteries leading from the heart to the brain) on one side. Furthermore, there was evidence of multiple small infarcts (clotting or small strokes) on an MRI scan. It became clear that her psychosis was at least exacerbated, if not caused, by these infarcts. The cause of these infarcts was eventually traced to the buildup of carotid artery disease. She eventually underwent surgery to repair the carotid blockage.
- Be suspicious if there is a history of recent onset of headaches, loss of function, unusual perceptions (tingling, dissociation, visual disturbances, paranormal experiences, or hallucinations – especially visual, olfactory, or tactile) or weight loss of a severe nature. Interestingly, the woman whose panic attacks were eventually found to be due to a B-12 deficiency sent her daughter to me several years later. Her daughter was having paranormal experiences that turned out to be related to a B-12 deficiency as well.
- Drugs, drugs, drugs! Ask every patient about over-the-counter drug use (which patients often consider harmless), when new medications were started (heart medications, birth control pills, homeopathic remedies), and how these medications correlate with the chronological onset of symptoms. Also get a careful history on alcohol and illicit drug use, which are very often underreported, hidden (e.g., patients with chronic pain often abuse pain medications), or assumed to be irrelevant. Remember that most over-the-counter or prescription medications can cause psychiatric symptoms.
About one year ago, I received a call from my mother, who casually informed me that she was on a new heart medication. Since she had always been in good health, I questioned her and found out that she had a recent onset of palpitations. The medication seemed to be helping. After getting more information, I decided it would be appropriate for her to have a cardiologist evaluate her. She was given a Holter monitor, which monitors the heart rate over 24 hours. It turned out that her palpitations were most common one to two hours after falling asleep. At first, this piece of information did not ring any bells, but soon she called me quite delighted, stating that she thought she had figured it out. Apparently, she had been taking a homeopathic medication (ginkgo biloba) that she thought was harmless. When she stopped this, the palpitations stopped and she was able to discontinue the heart medication.
Farther from home is the case of a 38-year-old woman recently referred for evaluation by her seventh therapist. After very thorough – and for the patient, anxiety provoking – history gathering, and actual charting of her moods and life events, it became clear that, while she had some mild to moderate depression intermittently throughout adulthood, her mood disorder became very significantly worse – and an anxiety disorder first developed – after her hysterectomy and estrogen replacement therapy (ERT) 10 years earlier. Discontinuation of her ERT resulted in a sharp reduction in psychiatric symptomatology.
Medical Mimic Definitions
T = Tumors
H = Hormones
I = Infectious and Immune Disease
N = Nutrition
C = Central Nervous system
M = Miscellaneous
E = Electrolyte Abnormalities and Environmental Toxins
D = Drugs